Sample Patient Registration Form

Introduction to Patient Registration Form:

In the field of medical patient registration refers to two different options. One option is related to collection of data pertaining to new patients and involves generation of patient record. The other option is related to collection of information that is used in computer assisted surgery which covers the accurate and detailed studies of medical imaging which are necessary to guide the computer safely and accurately in surgery.

Use of Sample Patient Registration Form:

Patient registration form is used when patients enter a new clinic, treatment center or hospital. It is most of the times mandatory for patients to fill out a form known as admission form that contains very basic information about the patients and medical history if any. This information includes the contact information of the patients, and also the payment guarantees, the designation of the party that is responsible for payment. This registration form also included information regarding insurance billing, particularly if a patient is entitled to insurance cover for health care expenses.


Implementation of Patient Registration Form in terms of verifying official record

During the process of patient registration, patients will have to provide information about insurance cards. The patient registration form has to be complete and detailed in every aspect and the patients should always ensure to update the information about medical history or contact details, if there is any change at any time. In case of emergency, sometimes a patient can undergo any required treatment without providing registration information, and any friend or family can fill the patient registration form and later the patient himself can verify the information and approve it. Just in case the patient is alone and has no assistance and has no identity at the time of admission, the hospital or clinic can temporarily set up registration.

Here is a preview of sample patient registration form along with download options.


Sample Form-1

Sample Patient Registration Form



Sample Form-2

Patient registration form