Patient Registration Patient InformationPatient Name(Required) First Last Responsible Party Name(Required)Emergency Contact(Required)Address(Required)P.O. Box Address (postal address)(Required)Email(Required) Phone(Required)BUS.PhoneCell PhoneSex(Required) Female Male Birthdate(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Referring Physician Name(Required)Marital status(Required) Married Single Divorced Other Employment status(Required) Employed Full-time Student Other Employer name(Required)Primary InsurancePrimary insurance Co. Name(Required)Primary insurance Co. Address(Required)Primary policy holder name(Required)Relationship to patient(Required)Employer (primary policy)(Required)Primary policy ID(Required)Primary group #(Required)Holder sex (primary policy)(Required) Male Female Holder birthdate (primary policy)(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary InsuranceSecondary insurance Co. Name(Required)Secondary insurance Co. Address(Required)Secondary policy holder name(Required)Relationship to patient(Required)Employer (secondary policy)(Required)Secondary policy ID(Required)Secondary group #(Required)Holder sex (secondary policy)(Required) Male Female Holder birthdate (secondary policy)(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Authorizations ConsentConsent AUTHORIZE TO PAY(Required) I agree to AUTHORIZE TO PAYI hereby authorize payment directly to the business of PET CT International at #35 Delancey Street, Nassau, Bahamas for medical benefits, if an, otherwise payable to me for services. I understand that I am financially responsible for charges not covered by my insurance.Consent AUTHORIZATION TO RELEASE INFORMATION(Required) I agree to AUTHORIZATION TO RELEASE INFORMATIONI hereby authorize PET CT International to release any information required in the course of my examination or treatment.Signature(Required)your name as a signatureThis field is hidden when viewing the formToday date(Required)
