Patient Registration - Nugent Family Counseling Center

Patient Information

Last Name *

First Name *

Date of Birth *

Gender *

Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone

Work Phone

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Primary Insurance Company *

Policy Number *

Group Number

Policyholder Name *

Policyholder Date of Birth *

Relationship to Patient *

Please briefly describe the reason for your visit *

Referral Source

I acknowledge that I have received and reviewed the HIPAA Notice of Privacy Practices *

I certify that the information provided above is accurate and complete to the best of my knowledge *

Your information is secure and confidential