Pullman Family Medicine
915 NE Valley Rd
Pullman, WA 99163
Phone: (509) 332-3548
Fax: (509) 332-5253

Patient Registration

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Fill-out the form below and then print it out. Your information will not be saved or sent.
Patient’s Legal Name:
S.S. #:
Preferred Name:

Due to updated Federal guidelines, we are required to obtain specific patient information. Please make sure you answer questions 1-7. Thank you.

(1) Patient’s Birthdate:
(2) Marital Status:
(3) Patient’s Gender:
(4) Race (Check One)
(5) Ethnicity (Check One)
(7) Preferred Method of Contact:
Local Address:
Billing Address:
Primary Number:
-
Secondary number:
-
E-mail:
May we contact you via Patient Portal?
Employer Name & Address:
Occupation:

If Patient is under age of 18, please fill out the next two sections:

1. Father’s Name:
Date of Birth:
S.S. #: (1)
Address:
Home Phone:
-
Work Phone:
-
Cell Phone:
-
E-mail:
Employer Name & Address:
Occupation:
2. Mother's Name:
Date of Birth:
S.S. #:
Address:
Home Phone:
-
Work Phone:
-
Cell Phone:
-
E-mail:
Employer Name & Address:
Occupation:
Name of Other:
Name:
Date of Birth:
S.S. #:
Address:
Home Phone:
-
Work Phone:
-
Cell Phone:
-
E-mail:
Employer Name & Address:
Occupation:

EMERGENCY CONTACT INFORMATION

Name:
Relationship:
Home Phone:
-
Work Phone:
-
Cell Phone:
-

PHARMACY INFORMATION

Preferred Pharmacy:
City:
State:
Phone number:
-
Preferred Mail Order Pharmacy:
Address:

INSURANCE INFORMATION

Name of Primary Insurance:
Effective Date:
Subscriber’s Name:
Birthdate:
Policy / Identification # (Include Alpha Prefix, if applicable):
Group #:
Copay:
Address:
Customer Service Phone #:
-
Relationship to Patient:
Name of Secondary Insurance (If Applicable):
Effective Date:
Subscriber’s Name:
Birthdate:
Policy / Identification # (Include Alpha Prefix, if applicable):
Group #:
Copay:
Address:
Customer Service Phone #:
-
Relationship to Patient:
Tertiary Insurance (If Applicable):
Effective Date:
Subscriber’s Name:
Birthdate:
Policy / Identification # (Include Alpha Prefix, if applicable):
Group #:
Copay:
Address:
Customer Service Phone #:
-
Relationship to Patient:
FAMILY ASSOCIATION INFORMATION
Please list names of all household members and their birthdate. Thank You.
I acknowledge the above Insurance/Demographic information is correct and that regardless of my insurance status I am solely responsible for payment of any professional services rendered to me, or on my behalf, whether or not paid by my insurance company.
Signature of Patient or Legal Guardian:
Date:
Printed Name:
Relationship to Patient: