Internal Medicine Patient Registration

To Advanced Wellness Internal Medicine

Private M.D., LLC Dr. Helen T. Gelhot

PATIENT REGISTRATION / DEMOGRAPHICS & BILLING RESPONSIBILITY Patient: Sex: M / F DOB: / /

(Last Name, First Name, MI)

Address: City: State: Zip: Best Phone # (Marital Status) S M D W Alt Phone# Email Employer (optional): Phone# Pharmacy:

(Name / Location / Phone#)

Spouse/Partner (or Guardian) Name: Phone# Emergency Contact: Use Spouse, Partner, Guardian Information Above; Yes or No

(If No,) Name: Phone# Billing Responsibility (If other than patient)

***COPY OF DRIVER'S LICENSE AND INSURANCE CARD IMAGE(S)*** Pg. 1

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