DAVZ02 Patient Registration

Davidson Family Medicine

104 Knox Court, Suite 100 Davidson, NC 28036
704-892-5454 Phone 704-892-5858 Fax

Dr. Craig White Dr. Emmett Montgomery Dr. Patricia White Debra Witkin, FNP Dr. Rebecca Montgomery Nicole Deschenes, FNP Deanna Dillon, FNP
Jamie Floyd, PA Timothy Kelley, PA.

PATIENT REGISTRATION
Patient Name*

First NameMiddle NameLast Name
Nickname
Date of Birth*

MonthDayYear
Date
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race
Preferred Language
Ethnicity

Hispanic or LatinoNot Hispanic or Latino
Marital Status
Employer
Work Phone Number
Please enter a valid phone number.
CONTACT INFORMATION
Primary Phone Number*
Please enter a valid phone number.
Is your primary phone number your

Home phone numberCell phone number
Other Contact Number
Please enter a valid phone number.
Is your is your other contact number your

Home phone numberCell phone number
Email
example@example.com
Preferred Communication - please pick one

PhoneEmail
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Parent Name (if patient is a minor)

First NameLast Name
BILLING INFORMATION
Primary Insurance Company*
Policy ID*
Subscriber Name*

First NameLast Name
Please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
Please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber Social Security Number
Do you have secondary insurance?*

YesNo
Secondary Insurance Company
Policy ID
Subscriber Name

First NameLast Name
Please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
Please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Social Security Number
I authorize Davidson Family Medicine, or any holder of medical or other information about me, to release to my insurance company information required in the course of my treatment for processing this or a related medical claim. I hereby authorize direct payment of any benefits payable for these medical services. I understand that I am financially responsible for payment of all services rendered, regardless of insurance coverage.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty: