PATIENTS INFORMATION
First Name*:
Last Name*:
Birth Date*:	(mm/dd/yyyy)
Gender*:	Male Female
SS#:	(SS# can be given at time of registration)
Marital Status*:	Married Single Widowed Divorced
How did you hear about Greeley Medical Clinic*:	Physician Referral Friend/word of mouth Yellow Pages Saw sign Website Newspaper ad Mail advertisement Other
PATIENTS HOME ADDRESS:
Street*:
City*:
State*:	Warning: mysql_num_rows(): supplied argument is not a valid MySQL result resource in /home/content/67/6504967/html/siteadmin/reg_info.php on line 181
Zip Code*:
PATIENT'S MAILING ADDRESS IF DIFFERENT:
PO Box:
City:
State:	Warning: mysql_num_rows(): supplied argument is not a valid MySQL result resource in /home/content/67/6504967/html/siteadmin/reg_info.php on line 226
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Email:
PATIENT'S EMPLOYMENT STATUS:
Employment Status*:	Employed Unemployed Disabled Retired Student
If Employed, Employer:
If student, are you covered under a parent's health insurance?:	No Yes
FINANCIALLY RESPONSIBLE PARTY:(FILL IN ONLY IF PATIENT IS A MINOR; FT STUDENT AND COVERED BY PARENT'S HEALTH INSURANCE; OR PATIENT CHOOSES TO MAKE SPOUSE FINANCIALLY RESPONSIBLE FOR HIS/HER ACCOUNT)
First Name:
Last Name:
Birth Date:	(mm/dd/yyyy)
SS#:	(SS# can be given at time of registration)
Marital Status:	Married Single Widowed Divorced
RESPONSIBLE PARTY'S HOME ADDRESS:
Street:
City:
State:	Warning: mysql_num_rows(): supplied argument is not a valid MySQL result resource in /home/content/67/6504967/html/siteadmin/reg_info.php on line 353
Zip Code:
MAILING ADDRESS IF DIFFERENT:
PO Box:
City:
State:	Warning: mysql_num_rows(): supplied argument is not a valid MySQL result resource in /home/content/67/6504967/html/siteadmin/reg_info.php on line 398
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Email:
PATIENT'S EMERGENCY CONTACT
First Name*:
Last Name*:
Relationship*:
Day Time Phone*:
PLEASE NOTE: Some of our Physicians are located at the Greeley Medical Clinic, Peakview Medical Center, Or Satellite Clinics. If you are uncertain about which location the appointment is at or if you have any questions about this form, please call the New Patient Pre-Registration Coordinator at (970) 392-4752.
GREELEY MEDICAL CLINIC 1900 16TH Street Greeley, CO 80631 Appointments: (970) 353-1551 PEAKVIEW MEDICAL CENTER 5881 W. 16th Street Greeley, CO 80634 Appointments: (970) 313-2700 SATELLITE CLINICS Please call (970) 392-4752 for Locations and directions.