Patient Registration Form Template in MS Word

The patient registration form template is word template for register and record the new patient information. This template is almost identical with earlier form template, only this one supposed for printing purpose. Like its early version, it can be used for clinics, small hospital, and healthcare.

 

TEMPLATE OUTLINE

There are some elements in patient registration form template:

Patient Registration Form Template Header

Enter the clinic or hospital name here. Below the big header, there are fields for Form Date and PCP ID field. PCP ID may be served as primary key. Or you can add form number or ID field as primary key.

patient registration form sample
patient registration form sample

Patient Information

The tables about recording the patient information. The fields are:

  • Patient Last, First, and Middle Name
  • Patient Title: for calling: Mr., Mrs., Miss, or Ms.
  • Marital Status: Single, Married, Divorced, Separated, or Widowed.
  • Legal Name: fill if the patient ever changed their name or using other name.
  • Birth Date
  • Age
  • Gender
  • Addresses fields: Street Address, PO box number, City, State, and ZIP Code
  • Social Security Number: outside of US, you can enter the patient identification ID.
  • Home or Cell Phone Numbers
  • Occupation
  • Employer name and Phone
  • Referral: how do you referred or find the clinic/hospital. If you select Doctor or Other, include their name or their relation to you.
  • Other family member: enter other patients related with current patient.
patient registration form doc
patient registration form doc

Financial and Insurance Information

This is the tables for who will pay the medical bill and insurance setup. The fields are:

  • Responsible person for the bill: Name, Birth Date, Address, and Phone Number
  • Is responsible person is patient too in current clinic or hospital?
  • Responsible person job field: Occupation, Employer Name, Address, and Phone
  • Is the patient Covered by Insurance?
  • Insurances: enter the Insurance Company name in your country or places, before printing or given to the patients
patient registration form pdf
patient registration form pdf

Below one is about the insurance subscriber information, which come in 2 insurance companies, one is primary while the other one is secondary. The fields are all same, except the secondary has no Co-Payment field:

  • Subscriber Name, SSN, birth date
  • Subscriber insurance group, policy, and co-payment
  • Patient relationship to Subscriber
patient registration forms for a medical office
patient registration forms for a medical office

In Case of Emergency

Where to enter who to be called or contacted if something happened to patient. The fields are:

  • Name
  • Relationship with patient
  • Home and Work Phone
patient registration form template pdf
patient registration form template pdf

Patient Registration Form Template Signing Agreement

It has fields for Patient’s sign (or Guardian if the patient still underage or disabled) and Date of signing. By signing this, the patient has been agreed with clinic/hospital terms.

 

HOW TO USE

To use patient registration forms for a medical office, first edit or replace the placeholder text. This placeholder text mainly the information for choices, such as Insurance Company name in Insurance Information section. You can change the header with the clinic/hospital header including logo, name, and contact details.

Next, you can change the font formatting style such as font type, size, or color. You can add watermark by going to Design tab > Watermark > Custom Watermark. Then navigate to the pictures location or create one.

This template is not using macros for form, unlike the previous one. Patient registration form doc is simply for printing and manual writing purpose. The radio button or check boxes in this patient registration form template is mainly pictures or symbol instead and not clickable.

You can turn this into digital use by using Developer tab by going to File > Options. On appeared window, choose Customized Ribbons, and tick the Developer tab before click OK. Secondly, you can convert it as patient registration form pdf. Then, using Adobe Acrobat or other application to edit the patient registration form template pdf to fill the form.

 

CONCLUSION

You can use this patient registration form sample right ahead or use it as the sample for your own template. You can add more details, such as patient health history or disabilities.

The patient registration form template can be downloaded after you click:

Patient Registration Form Template

For clinics or small hospital or healthcare, you may try this patient registration form template. Like its name, the main purpose is to record the patient. It can be used as patient registration forms for a medical office, if your company provide medical healthcare.

 

Patient Registration Form Design

There are some elements in patient registration form template:

Patient Registration Form Template Header

This is where to enter the clinic or hospital name. It has Form Date and PCP ID field. The PCP ID could be served as primary key.

patient registration form template pdf
patient registration form template pdf

Patient Information

The tables about recording the patient information. The fields are:

  • Patient Last, First, and Middle Name
  • Patient Title: drop down menu: Mr., Mrs., Miss, or Ms.
  • Marital Status: drop down menu: Single, Married, Divorced, Separated, or Widowed.
  • Legal Name: fill if the patient ever changed their name.
  • Birth Date: Date/Time field.
  • Age
  • Gender
  • Address
  • Social Security Number: outside of US, you can enter Patient identification ID.
  • Home and Cell Phone Numbers
  • Occupation
  • Employer name and Phone
  • Referral: how do you referred or find the clinic/hospital. If you select Doctor’s name, enter it. If you select the other one, choose the value from drop down menu.
  • Other family member: enter other patients related with current patient.
patient registration forms for a medical office
patient registration forms for a medical office

Patient Financial or Insurance Information

patient registration form in hospital
patient registration form in hospital

 

This is the tables for who will pay the medical bill and insurance setup. The fields are:

  • Responsible person Name, Birth Date, Address, and Phone Number
  • Patient Status in the clinic/hospital
  • Covered by Insurance
  • Occupation, Employer Name, Address, and Phone
patient information sheet template microsoft word
patient information sheet template microsoft word

Below one is about the insurance, which come in 2 insurance companies, one is primary while the other one is secondary. The fields are all same, except the secondary has no Co-Payment field:

  • Subscriber Name, SSN, birth date
  • Subscriber insurance group, policy, and co-payment
  • Patient relationship to Subscriber

In Case of Emergency

Where to enter who to be called or contacted if something happened to patient. The fields are:

  • Name
  • Relationship with patient
  • Home and Work Phone
free new patient medical forms
free new patient medical forms

Patient Registration Form Template Signing Agreement

It has fields for Patient’s sign (or Guardian if patient still underage) and Date of signing. By signing this, the patient has been agreed with clinic/hospital terms.

 

HOW TO USE PATIENT REGISTRATION FORM

To use patient information sheet template microsoft word, simply input the provided fields. The field with [Choose an Item] value means that it has been provided with drop down menu.

You can change the header with the clinic/hospital header including logo, name, and contact details.

 

MODIFY PATIENT REGISTRATION FORM

Modifying patient registration form in hospital template is medium. It’s using some Developer features like radio button or drop down menu, so you may need skill in creating UI.

To modify, first open the Developer tab by going to File > Options. On appeared window, choose Customized Ribbons, and tick the Developer tab before click OK.

On Developer tab, you can add UI features, such as checkbox or radio button.

To change the value in drop down menu, first select the field. Then in Developer tab > Controls Group > Properties. On the dialog box, on the bottom, select the value and click Modify. A new dialog box will appear, replace the value name. You can use Add or Remove button to add or delete the value too.

Bug

Sometimes, the patient registration form template may display an error in the radio button: if you select Yes/No button in a field, next time you choose the Yes/No in other field, the value in previous field would be disappear.

To fix this, on Developer tab > Design Mode. Delete the Yes and No radio buttons in one of the field. Then add only one radio button. Select and right click > Properties. On Caption row in dialog box, rename the value. Copy the radio button and change the caption into No. Do this to all the fields with Yes/No.

 
The free new patient medical forms can be printed blank for manual writing. It can be converted into patient registration form template pdf.

The can patient registration form template be downloaded after you click: