PATIENT REGISTRATION FORM              
Michele Schneider MD, LLC  
Family Medicine  
871 Baltimore Pike, #33  
Glen Mills, PA 19342  
610-742-1500, Fax: 1-888-264-2168  
   
PATIENT INFORMATION  
Last Name:     First Name:   Middle Initial:  Title:    Relationship Status:  
      ___Mr.  ___Mrs.  ___Miss ___Single  ___Married  ___Partnered
            ___Ms.     ___Dr. ___Divorced     ___Widowed
Is this your legal name? If not, what is your legal name? Former/Maiden Name (if any): Birth Date:   Gender:
___Yes     ___No                 ___Female
                    ___Male
Street Address:             Home Phone Number:  
                     
City, State and Zip code:             Work Phone Number:  
                     
Occupation:     Employer:         Cell Phone Number:  
                     
Preferred Pharmacy Name and Number:         Social Security Number:  
                     
Whom may we contact in case of emergency?         Relationship to you:  
                     
Emergency contact home phone number: Emergency contact work phone number: Emergency contact cell phone number:
                     
 
BILLING INFORMATION        
Person Resonsible for Bill: Address (if different):       Home Phone Number:  
___Self (skip to Primary Insurance            
Information Section)         Work Phone Number:  
___Other:                    
Relationship to Patient:   Date of Birth: Social Security Number:   Cell Phone Number:  
                     
 
PRIMARY INSURANCE INFORMATION      
Insurance Company:             ___PPO ___HMO  
                     
Is this an employer plan? If so, name of employer:         __None (Personal Policy)  
                     
Subscriber Name:   Subscriber Social Security Number: Birth Date:   Patient's Relationship to Subscriber:
                     
Group Number:   Subscriber/Member/Policy ID: Effective Date: Copay(PCP) / Deductible:  
                     
 
SECONDARY INSURANCE INFORMATION    
Insurance Company:  ___None            ___PPO ___HMO  
                     
Is this an employer plan? If so, name of employer:         __None (Personal Policy)  
                     
Subscriber Name:   Subscriber Social Security Number: Birth Date:   Patient's Relationship to Subscriber:
                     
Group Number:   Subscriber/Member/Policy ID: Effective Date: Copay(PCP) / Deductible:  
                     
 
The information I have provided on this form is true to the best of my knowledge.  
Patient Signature             Date: