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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

*First Name:

*Last Name:

Preferred Name:

*DOB:

*Sex at Birth:

*Email Address:

Social Security #:

*Is the patient 17 years or younger?

Yes

*Mailing Address:

APT #:

*City:

*State:

*Zip:

*Cell Phone:

*Home Phone:

Other Phone:

*Ethnicity:

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

*Race:

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

*Preferred Spoken Language:

English

Spansih

Portugese

Other

*Sexual Orientation:

Lesbian, gay or homosexual

Straight or heterosexual

Bisexual

Do not know

Choose not to disclose

Other

*Gender Identity:

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

*Preferred Pronouns:

She, her, hers

He, him, his

They, them, theirs

Other

Emergency Contact

*Name;

*Relationship:

*Phone:

*Street Address:

APT #:

*City:

*State:

*Zip:

Additional Information

*Have you ever served in the US military?

Yes

*How did you hear about us?

*Do you have any specific communication needs/preferences?

Vision

Hearing

Other

None

Pharmacy Information

*Name:

*Phone:

*Mailing Address:

*City:

*State:

*Zip:

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. After selecting the file, click the upload button to upload them. Click the X to delete a file.

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Patient Registration Form

Patient Demographics

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