Patient Registration Form- English

Please fill out all pertinent information pertaining to your visit. Once completed, hit "Submit" and your form will be sent directly to our office. Upon submission, the option to print this form for your records is also available.

Submitting patient information online is not mandatory, although if not completed on our website you will be required to fill out our Patient Information Form in its entirety at the time of your visit.

Please note: All forms submitted after 5:00pm EST will not be received until the following business day.
Although, you may print all information completed online and bring it to our office at the time of your visit.
Thank you for your understanding.

PATIENT INFORMATION

First name:

Last name:

Middle initial:

* Email:

Address:

Apt. #:

City:

State:

Zip code:

Home phone:

Cell phone:

Email address:

Social Security #

Date of Birth:

Age:

Sex:

male female

Marital status:

Single Married Divorced Widowed Other

Reason for todays visit:

* How did you hear about Fastcare?

EMPLOYER INFORMATION

Company name:

Addres:

City, State, Zip

Phone:

CONTACT INFORMATION (in case of emergency who should be notified?)

Name:

Relationship:

Phone #:

Name of nearest relative not living with you:

Address:

Relationship:

Phone #

FAMILY PHYSICIAN

Name:

Address:

City, State, Zip:

Phone #:

Fax #:

As a courtesy, your medical notes will be faxed to your physician unless you indicate otherwise:

do not fax my notes to my physician

INSURANCE INFORMATION (must be completed entirely)

Primary insurance:

Name of insured:

Date of birth:

Policy #:

Group #:

Relation to patient:

Secondary insurance:

Name of insured:

Date of birth:

Policy #:

Group #:

Ralation to patient:

WORKERS COMPENSATION INSURANCE
If you have a work related injury or illness, please complete the following:

Date of injury:

Supervisor:

Phone #:

Are you represented by a lawyer?

Yes No

Name:

Phone #

ASSIGNMENT, RELEASE AND FINANCIAL RESPONSIBILITY

I authorize release of medical information to process claims to my insurance company and request that benefits be paid directly to Fast Care. I understand and agree that regardless of my insurance sources, I am ultimately responsible for the balance of my account for any professional services rendered. I authorize the use of my signature on all insurance submissions. I have read all the information on this sheet and certify this information to be true and correct to the best of my knowledge.

Print name of Patient, Guardian or Personal Representative

Date

At FastCare, we take all appropriate precautions when it comes to protecting your individual health information. We are required by federal law to provide a Notice of Privacy Policy that describes how health information that we maintain about you may be used or disclosed. The notice describes each use and disclosure that we are permitted to make, and provides a description of your rights and our obligations under federal and state privacy laws.

Notice of Privacy Policy

By submitting your information, you are acknowledging you have read our Notice of Privacy Policy above.

Required field*

Enter Validation Code (case sensitive)

Fast Care LLC. 20601 E. Dixie Hwy Suite #340, Aventura, FL 33180 | Phone: 786-923-4000 | Fax: 786-923-4001 | Email: info@myfastcare.com