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PATIENT REGISTRATION QUESTIONNAIRE PATIENT NAME: __________________________________________________________________________________________ Last First Middle Initial

__________________________________________________________________________________________ Social Security Number Sex: Male / Female Date of birth __________________________________________________________________________________________ Address City State Zip code Home phone: Work Phone: Cell

Partner

Phone: Marital Status: (circle one) Single / Married / Divorced / PATIENT / INSURANCE Is partner covered under this plan? Yes / No (Circle) __________________________________________________________________________________________ Subscriber Name __________________________________________________________________________________________ Social Security Number Age Date of Birth __________________________________________________________________________________________ Address (if different from above) Telephone Number __________________________________________________________________________________________ Employer Occupation __________________________________________________________________________________________ Employer Address City State Zip code __________________________________________________________________________________________ Insurance Company Effective Date __________________________________________________________________________________________ Group Number Policy Number ID/Subscriber Number PARTNER / INSURANCE Is patient covered under this plan? Yes / No (Circle) __________________________________________________________________________________________ Subscriber Name __________________________________________________________________________________________ Social Security Number Age Date of Birth __________________________________________________________________________________________ Address (if different from above) Telephone Number __________________________________________________________________________________________ Employer Occupation __________________________________________________________________________________________ Employer Address City State Zip code __________________________________________________________________________________________ Insurance Company Effective Date __________________________________________________________________________________________ Group Number Policy Number ID/Subscriber Number

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IN CASE OF EMERGENCY

__________________________________________________________________________________________ Name Address Telephone Number Relationship

__________________________________________________________________________________________ Name Address Telephone Number Relationship

__________________________________________________________________________________________ Prior name(s) of patient

__________________________________________________________________________________________ Patient’s Signature Date Responsible Party

Dear Patient,

To optimize your visits with our doctors, nurses, and nurse practitioners, we kindly ask you to arrange for childcare if you have children. All of your attention is needed to fully understand the important and detailed information you will need for treatments.

Thank you for your understanding. We appreciate the trust you've placed in us and the opportunity to partner with you in your health care.

Palo Alto Medical Foundation Fertility Physicians and staff.