You are completing Step 2 in the Colonnades Family Medicine Registration Process

Step #2 - Patient Information

Please take a few minutes to complete your information at Colonnades Family Medicine.

*Denotes a required field.

PATIENT CONTACT INFORMATION
Name:    
Address 1: *
Address 2:
City: *
State:
Zip Code: *
Country:
Home Phone:
Work Phone:
Work Fax:
Mobile Phone:
Other Phone 1:
Other Phone 2:
Pager:
E-mail:
Web Site Address:

PATIENT DEMOGRAPHICS
Date of Birth:  MM/DD/YYYY *
SSN:
# in Household(inc. yourself):
Retirement Date:  MM/DD/YYYY
Gender:
Race:
Religion:
Marital Status:
Employment Status:
Occupation:

If employed, complete the following section
Employer Name:

Job Title:

Employer Address:

Employed From: MM/DD/YYYY
Employed To: MM/DD/YYYY

Student Status:

Do you have a will or power of attorney?
Yes
No

Leisure Activities/Special Interests:
Please feel free to add any additional information about yourself:

PATIENT INSURANCE INFORMATION
Insurance Company:
Plan:
ID:
Group #:
Primary Name on Policy
Date of Birth of Primary:  MM/DD/YYYY
Does your insurance have a pre-existing condition clause? Yes   No   If Yes, how long? 

How did you find out about Colonnades Family Medicine?
Search Engine
Referral from a Physician
Referral from a Friend
Newspaper Article/Advertisement
Mail
Other, please specify:

Would you like information on our Pampered Patient Program?
Yes
No

Please add any general information:


You may also print this form and mail or fax it to:

Colonnades Family Medicine
Stonewood Commons I
101 Bradford Road
Suite 220
Wexford, PA 15090

phone: (724) 940-5555
fax: (724) 940-5556