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Patient Registration Form

  • Welcome to St. Beardyman's Hospital
    Please complete this registration form
  • 1. What is your full name? *

    As it appears on your birth certificate or medical records.
  • 2. What is your email address? *

    We'll use this to keep you up to date with appointments and news.
    Please, enter e-mail address in a form e.g.: john.doe@email.com
  • 3. What is your biological sex? *

    You can give only one answer.
  • 4. Which year were you born in? *

    q
  • 5. In which month of 1991 were you born? *

    You can give only one answer.
  • 6. On which day of [ANS_5] [ANS_4] were you born? *

    q
  • 7. Please upload a picture of yourself for our records.

    We accept images in .png and .jpg formats.
    Accepted file formats are: png, jpg, jpeg. The maximum file size is 5 MB.
  • 8. Do you have health insurance? *

    You can give only one answer.
  • 9. What is the name of your health insurance company? *

  • 10. What is your health insurance policy number? *

  • 11. What is the street address of your insurance company?

  • 12. What is their city and state?

  • 13. What is their postal or zip code?

  • 14. Please upload a copy of your medical insurance documents.

    We'll check the details you provided against this document.
    Accepted file formats are: jpg, pdf, jpeg. The maximum file size is 5 MB.
  • 15. What is your blood type? *

    You can give only one answer.
  • 16. Do you have any allergies? *

    You can give only one answer.
  • 17. Do you have any allergies? *

    You can give only one answer.
  • 18. What are you allergic to? *

    Be careful to list all allergies, including any allergies to medication.
  • 19. Are you taking any medications currently? *

    You can give only one answer.
  • 20. Which medications are you currently taking? *

    Be careful to list all of them.
  • 21. How frequently do you consume alcohol?

    Please be honest.
    You can give only one answer.
  • 22. How frequently do you smoke?

    Please be honest.
    You can give only one answer.
  • 23. What is the full name of your emergency contact? *

  • 24. What is your relationship with this person? *

    You can give only one answer.
  • 25. What is their phone number? *

    q
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