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Patient Registration Form

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Patient Registration Form

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Patient Demographics

All fields marked with * are required.

*Please select one of the following:

Ossining Dental	Brewster Dental	Mt Kisco Medical	Brewster Medical
Port Chester Dental	Saugerties Dental	Port Chester Medical	School Based Health Center Medical
Sleepy Hollow Dental	School Based Health Center Dental	Sleepy Hollow Medical	Saugerties Medical
Mamaroneck Dental	Ossining Medical	Mamaroneck Medical

*Last Name:

*First Name:

Preferred Name:

*DOB:

*Sex at Birth:

Social Security #:

*Mailing Address:

Apt #:

*City:

*State:

*Zip:

*Home Phone:

*Cell Phone:

Work Phone:

*Email Address (for patient portal registration):

*Is the patient 17 years or younger?

Yes

*Sexual Orientation:

Lesbian, gay or homosexual	Do not know
Straight or heterosexual	Choose not to disclose
Bisexual	Other

*Gender Identity:

Male	Genderqueer, neither exclusively male nor female
Female	Choose not to disclose
Female-to-Male (FTM)/Transgender Male/Trans Man	Additional gender category or other
Male-to-Female (MTF)/Transgender Female/Trans Woman

*Preferred Pronouns:

She, her, hers	Choose not to disclose
He, him, his	Other
They, them, theirs

*Preferred Spoken Language:

English

Spansih

Portugese

Other

*Race:

American Indian or Alaskan Native	Korean
Asian	Native Hawaiian
Asian Indian	Other Pacific Islander
Black or African American	Samoan
Chinese	Vietnamese
Filipino	White
Guamanian or Chamorro	Declined to Specify
Japanese

*Ethnicity:

Chicano	Mexican
Cuban	Mexican American
Hispanic or Latino	Puerto Rican
Not Hispanic or Latino	Declined to Specify

Emergency Contact

Relationship:

First Name:

Last Name:

Mailing Address:

APT #:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Insurance Information

*Do you have insurance?

Yes

Please upload a picture of your insurance card. Front & Back. Please remember to click "Upload Form Attachment" after you select your file, or your file will not be attached.
Please click "choose file" to select a file. You may upload up to five files. Once selected, the file will upload automatically. Click the X to delete a file.

Pharmacy Information

Name:

Address:

City:

State:

Zip:

Telephone:

Additional Information

*Have you ever served in the US military?

Yes

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Patient Registration Form

Patient Demographics

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