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New Patient Registration

New Patient Registration

New Patient Registration

Registration Date(Required)

MM slash DD slash YYYY

Time

Hours

:

Minutes

AM/PM

Patient Name(Required)

First Last

Sex(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Marital Status(Required)

Is The Patient Younger than 18?(Required)

Emergency Contact

Name(Required)

First Last

Relationship to Patient(Required)

Phone(Required)

Family Doctor Name

First Last

Family Doctor Phone

Preferred Pharmacy

Pharmacy Phone

Health History

Reason for Registration(Required)

Additional Notes

Currently Taking any Medications?(Required)

Yes

No

Insurance Information

Primary Insurance Company(Required)

Insurance ID(Required)

Patient Relationship to Policy Holder(Required)

Policy Holder's Name(Required)

First Last

Policy Holder's Date Of Birth(Required)

MM slash DD slash YYYY

Does the Patient Have a Secondary Insurance?(Required)

Yes

No

Patient Relationship to Guarantor(Required)

Guarantor Social Security Number

Is the Guarantor's Address the Same as the Patient?(Required)

Yes

No

How Do You Prefer to Be Contacted?(Required)

Select All

Email

Phone

SMS

Cook Behavioral Health

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Address
347 W Berry St STE 200,
Fort Wayne, IN 46802

Contact
Phone: (260) 483-2400
Fax: (260) 222-0003