Patient Registration - Figure 2.10

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Using the information below, fill out the registration form provided here. You will have to invent information for some of the categories in the registration form.

Your patient (choose a name) is 17 years old. His or her primary care physician is Dr. Lundgren. The patient is single and lives with his or her parents at 400 S. Main Street in Star Prairie, Texas 74260. Their home phone number is 123-701-0197. The patient is a student. The emergency contact is the patient’s mother, Rita. Her number is the same as the patient's home phone number. Rita works as a preschool teacher at Playtime Child Care Center. The patient's father, Joe, works as a mechanic at Smith Auto Body Shop. The family's primary insurance company is DC Health Plan. The copay is $25.00. The policy number is 03654, and the group number is 06172. The insurance is in the father – Joe's – name.

Patient Information

Spouse or Parent/Responsible Party Information

Second Parent Information

Insurance Information