Online Registration

Chart Number

Primary Care Physician (PCP)*

Physician's Name Physician's City

Physician or Appointment Type*

Date of Appointment

A. Patient Information

Name*

First Name MI Last Name

Sex*

Male
Female

Date of Birth*

Address

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

Patient Home Phone*

Cellular Phone

Marital Status*

Race*

American Indian or Alaska Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Other
Unknown
Declined

Ethnicity*

Hispanic or Latino
Not Hispanic or Latino
Unknown
Declined

Language*

Arabic
Chinese
English
French
Japanese
Spanish
Vietnamese

Preferred Method of Contact*

Cell-Phone
Home Phone
Email
Text

If you do not have an emergency contact, click here

Emergency Contact Details

Emergency Contact*

Relationship*

Daytime Phone*

Cellular Phone

Additional Contact Details

Additional Contact

Relationship

Daytime Phone

Cellular Phone

B. Person Responsible for Payment

(If patient is a child, the person who has custody)

Click here if the person responsible is the same as the patient in Section A

Name*

First Name Last Name

Date of Birth*

Sex*

Male
Female

Address*

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

Email

Home Phone*

Cellular Phone

C. Health Insurance Information

Do you have Health Insurance?*

Yes
No

Please bring all insurance cards to your appointment

Insurance Company*

Policy Number*

Group Number

Address to File Medical Claims

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

Name of Policy Holder*

Effective Date*

Relation to Patient*

Birth Date*

Insurance Employee Name

Patient Co-Pay for Primary Care Physician

Patient Co-Pay for Specialist

D. Secondary Insurance Information

Do you have Secondary Health Insurance?*

Yes
No

Please bring all insurance cards to your appointment

Insurance Company*

Policy Number*

Group Number

Address to File Medical Claims

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

Name of Policy Holder*

Effective Date*

Relation to Patient*

Birth Date*

Insurance Employee Name

Patient Co-Pay for Primary Care Physician

Patient Co-Pay for Specialist

By checking this box, I agree that the information is accurate and that I am responsible for notifying The Toledo Clinic of any changes.

This is a Test Alert

Pre-Registration Form

A. Patient Information

Emergency Contact Details

Additional Contact Details

B. Person Responsible for Payment

C. Health Insurance Information

D. Secondary Insurance Information