Please note that it is important to fill in all the fields before submitting. Thank you.

PATIENT REGISTRATION FROM

Full Name *:

Street Address :
City :
State :
Zip Code :
SSN:
Birth Date:
Age:
Marital Status	S M W D

Home Phone
Work Phone :
Driver’s License# :
E-Mail Address :
Employer’s Address:
Emergency Contact Name & Phone Number:

Primary Insurance Company :
Phone Number :
Name of Insured :
SSN of Insured :
Date of Birth of Insured :
Relationship to Insured :
Primary ID Number :
Group Number :
Name of Insured :
Secondary ID Number :

I, the undersigned, grant permission to Dr. Martin Franklin to disclose medical information to other treating physicians regarding my care. I authorize the release to the Health Care Financing Administration or said insurance company and its agents any medical information about me to determine benefits payable for related services. I understand that I, the undersigned, am legally responsible for all fees related to medical services rendered. I request the payment of authorized Medicare or health insurance benefits are to be made to Franklin Clinic of Dr. Martin Franklin for services furnished to me.


Patient’s Signature* (Enter your name)	Date