New Patient Registration Form – Test

Patient Registration Form

Please complete your registration before your visit.

Welcome / Bienvenido

Please select your preferred language to begin the new patient registration form.

English Start Patient Registration Español Comenzar Registro del Paciente

350 W North Ave, Addison, IL 60101
Phone: (630) 940-9573

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Patient Registration Form

Please complete this form before your visit.

📍

350 W North Ave,
Addison, IL 60101

📞

(630) 940-9573

New Patient Registration Form

Please complete this form before your visit. Fields marked with * are required.

1. Patient Information

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Preferred Language

Phone Number *

Email Address *

Home Address *

City

State

ZIP Code

Emergency Contact Name *

Emergency Contact Phone *

Relationship to Patient

2. Insurance Information

Insurance Provider

Member ID

Group Number

Primary Insurance Holder Name

Relationship to Patient

Upload Insurance Card Front

Upload Insurance Card Back

3. Medical History

Check all that apply:

Diabetes High Blood Pressure High Cholesterol Heart Disease Asthma COPD / Emphysema Sleep Apnea Thyroid Disorder Arthritis Cancer Stroke Kidney Disease Liver Disease Anxiety Depression Migraines / Headaches Seizures / Epilepsy GERD / Acid Reflux Seasonal Allergies Blood Clots Anemia Autoimmune Disorder Hepatitis Ulcers None

Other Medical ConditionsList Any Allergies *Current Medications *Past Surgeries or Major Illnesses

4. Visit Information

Reason for Today’s Visit *

When did symptoms start?

Pain Level

5. Preferred Pharmacy

Pharmacy Name

Pharmacy Phone

Pharmacy Address

City

State

ZIP Code

6. Consent & Acknowledgment

I confirm that the information provided is accurate and complete. * I consent to receive medical treatment from North Ave Immediate Care and its providers. * I acknowledge receipt of the Notice of Privacy Practices / HIPAA policy. * I authorize release of medical information as needed for treatment, payment, and healthcare operations. * I understand that I am financially responsible for charges not paid by insurance. *

7. Digital Signature

Patient Full Name as Signature * Date *

Your Privacy Matters:
Your information should be handled securely and only used for clinic registration, treatment, payment, and healthcare operations.

✅ Thank you! Your form has been submitted. Please wait a few seconds while we save your PDF.

After submitting, a confirmation page may open. The PDF will be saved to the clinic Google Drive folder.

Note: To collect patient medical information online, use HIPAA-compliant hosting and secure form storage.

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Formulario de Registro del Paciente

Complete este formulario antes de su visita.

📍

350 W North Ave,
Addison, IL 60101

📞

(630) 940-9573

Formulario de Registro de Nuevo Paciente

Complete este formulario antes de su visita. Los campos marcados con * son obligatorios.

1. Información del Paciente

Nombre *

Segundo Nombre

Apellido *

Fecha de Nacimiento *

Género *

Idioma Preferido

Número de Teléfono *

Correo Electrónico *

Dirección *

Ciudad

Estado

Código Postal

Nombre del Contacto de Emergencia *

Teléfono del Contacto de Emergencia *

Relación con el Paciente

2. Información del Seguro

Proveedor de Seguro

ID de Miembro

Número de Grupo

Nombre del Titular Principal del Seguro

Relación con el Paciente

Subir Frente de Tarjeta de Seguro

Subir Reverso de Tarjeta de Seguro

3. Historial Médico

Marque todo lo que corresponda:

Diabetes Presión Alta Colesterol Alto Enfermedad del Corazón Asthma COPD / Emphysema Apnea del Sueño Trastorno de Tiroides Arthritis Cancer Derrame Cerebral Enfermedad Renal Enfermedad del Hígado Ansiedad Depresión Migrañas / Dolores de Cabeza Convulsiones / Epilepsia GERD / Acid Reflux Alergias Estacionales Coágulos de Sangre Anemia Trastorno Autoinmune Hepatitis Úlceras Ninguna

Otras Condiciones MédicasListe Cualquier Alergia *Medicamentos Actuales *Cirugías Pasadas o Enfermedades Graves

4. Información de la Visita

Razón de la Visita de Hoy *

¿Cuándo comenzaron los síntomas?

Nivel de Dolor

5. Farmacia Preferida

Nombre de Farmacia

Teléfono de Farmacia

Dirección de Farmacia

Ciudad

Estado

Código Postal

6. Consentimiento y Reconocimiento

Confirmo que la información proporcionada es precisa y completa. * Doy mi consentimiento para recibir tratamiento médico de North Ave Immediate Care y sus proveedores. * I acknowledge receipt of the Notice of Privacy Practices / HIPAA policy. * I authorize release of medical information as needed for treatment, payment, and healthcare operations. * I understand that I am financially responsible for charges not paid by insurance. *

7. Firma Digital

Nombre Completo del Paciente como Firma * Date *

Su Privacidad Importa:
Su información debe manejarse de forma segura y solo usarse para registro clínico, tratamiento, pago y operaciones de atención médica.

✅ Thank you! Your form has been submitted. Please wait a few seconds while we save your PDF.

Después de enviar, puede abrirse una página de confirmación. El PDF se guardará en la carpeta de Google Drive de la clínica.

Note: To collect patient medical information online, use HIPAA-compliant hosting and secure form storage.

✓

Thank You!

Your registration form has been submitted successfully.

North Ave Immediate Care has securely received your information.

What happens next?
Our team will review your registration information before your visit. If you need immediate assistance, please call (630) 940-9573.

Return to Home

New Patient Registration Form

Patient Registration Form

Welcome / Bienvenido

Patient Registration Form

New Patient Registration Form

1. Patient Information

2. Insurance Information

3. Medical History

4. Visit Information

5. Preferred Pharmacy

6. Consent & Acknowledgment

7. Digital Signature

Formulario de Registro del Paciente

Formulario de Registro de Nuevo Paciente

1. Información del Paciente

2. Información del Seguro

3. Historial Médico

4. Información de la Visita

5. Farmacia Preferida

6. Consentimiento y Reconocimiento

7. Firma Digital

Thank You!

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