Southern Colorado MFM » Patient Registration Form

You may either (1) fill out the form below and submit it online, or (2) download the form to complete it and then fax it to (888) 310-9460 (Colorado Springs) or (866) 309-4287 (Pueblo and Alamosa) or bring it in with you when you visit the office.

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Southern Colorado Maternal Fetal Medicine
6071 E. Woodmen Road, Suite 440
Colorado Springs, CO 80923
(719) 622-3442

PATIENT REGISTRATION FORM

Full Name

Maiden Name

Marital Status

Address

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Cell Phone

Home Phone

Work Phone

Date Of Birth (DOB)

SSN#

Referred By

Pharmacy

Location

Race

Ethnicity

Emergency Contact (Required)

Phone

Relationship to Patient

Person Responsible for Payment (if patient is a Minor)

Date of Birth (DOB)

SSN#

Phone

Address

INFORMATION AUTHORIZATION RELEASE CONSENT

Southern Colorado Maternal Fetal Medicine is in accordance with the Federal Laws to the fullest extent. HIPPA is the privacy act that protects patient medical information from being disclosed to anyone for any reason without written consent from the patient. The form below will allow us to release information about you, the patient, to individual(s) who are non-medical in relation to you. This consent form can be changed by patient at any time for any reason. This form is valid for one year from the date it was signed.

Please indicate phone number(s) where Southern Colorado Maternal Fetal Medicine may leave voice messages:

Phone

Choose one option below

Option 1 - Authorizing Patient Information to be Released

Authorized Individuals
These individual(s) have been selected by the patient listed above.

Name One

Relation

Name Two

Relation

Note: You will be required to sign and date this document when you visit our office

Option 2 - Authorizing Patient Information NOT to be Released

By signing this section below, you are choosing NOT to release ANY of the above information to ANY individual(s) other than yourself. This means that spouses, children, parents, family members, etc. cannot access any information regarding your care at SCMFM. I am aware that SCMFM privacy and office policies are available in Southern Colorado Maternal Fetal Medicine office.

Note: You will be required to sign and date this document when you visit our office

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