Existing Patient Registration – Greater Houston OB/GYN

All fields are required; if not applicable, use n/a or 000-000-0000.

First Name(Required)

Middle Name(Required)

Last Name(Required)

Home Address(Required)

Apt #

City(Required)

State(Required)

Zip(Required)

Sex(Required)

Date of Birth(Required)

Marital Status(Required)

Single

Married

Widow

Divorced

Phone (Home)(Required)

Cell(Required)

Work(Required)

Referred By(Required)

Employment(Required)

Employer(Required)

Occupation(Required)

Your Email(Required)

Spouse's Name(Required)

Phone(Required)

Emergency Contact(Required)

Phone(Required)

Insurance Information / Responsible Party

Primary Insurance Company(Required)

Upload Photo of your Driver's License

Max. file size: 300 MB.

Upload Photo of FRONT of Insurance Card

Max. file size: 300 MB.

Upload photo of BACK Insurance Card

Max. file size: 300 MB.

Policy #(Required)

Group Number(Required)

Card Holder's Name(Required)

Middle(Required)

Last Name(Required)

Date of Birth(Required)

Sex(Required)

Relationship to Patient(Required)

Self

Spouse

Parent

Employer(Required)

Employer Phone #(Required)

Secondary Insurance(Required)

Upload Photo of your Driver's License

Max. file size: 300 MB.

Upload photo of BACK Insurance Card

Max. file size: 300 MB.

Upload Photo of FRONT of Insurance Card

Max. file size: 300 MB.

Policy #(Required)

Group #(Required)

Card Holder's First Name(Required)

Middle Name(Required)

Last Name(Required)

Date of Birth(Required)

Sex(Required)

Relationship to Patient(Required)

Self

Spouse

Parent

Employer(Required)

Employer Phone #(Required)

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non covered services.

Signature(Required)

Date Signed(Required)

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims.

Signature(Required)

Date Signed(Required)