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Person Completing this Form:
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To Complete this form please have available your
Personal Information
Home Address/Number
Work Address/Number
Primary Insurance Information
Secondary Insurance Information
Referral Name
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Patients General Information
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Patients First Name
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Patients Middle Name
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Patients Last Name
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PatientsDate Of Birth MM/DD/YYYY
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Occupation of Patient
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Home Phone (with Area Code)
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Home Address #1 of Patient
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Home Address #2 Of Patient
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City
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State
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Zip Code
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Work Address of Patient
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Work Phone (with Area Code
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Work City
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Work State
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Work Zip Code
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Emergency Contact
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Emergency Contact Phone Number
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Relationship to Emergency Contact
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Referred by Friend/Family
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Referred by a Doctor
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Primary Care or Family Physician
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Date of Injury or Onset of Condition
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Reason For Todays Visit
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Pharmacy Name
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Pharmacy Address
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Pharmacy Fax
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Pharmacy Phone/Area Code
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Pharmacy City
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Pharmacy State
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Pharmacy Zip Code
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Insurance Plan
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Insurance ID Number
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Insurance Phone Number
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Effective Date of Insurance
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Insurance Address
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Insurance City
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Insurance State
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Insurance Zip Code
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Policy Holders Name
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Policy Holders Date of Birth
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Relationship To Policy Holder
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Policy Holders Address
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Policy Holders Employer
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Policy Holder City
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Policy Holder State
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Policy Holder Zip Code
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Secondary Insurance Information
(such as Medicare secondaries or supplementals,
Personal Injury Cases, Workers Compenstion Claims)
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Insurance Plan
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Insurance ID Number
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Insurance Phone Number
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Effective Date of Insurance
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Insurance Address
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Insurance City
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Insurance State
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Insurance Zip Code
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Policy Holders Name
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Policy Holders Date of Birth
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Relationship To Policy Holder
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Policy Holders Address
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Policy Holders Employer
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Policy Holder City
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Policy Holder State
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Policy Holder Zip Code
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Guardianship or Individuals under 18 years of age
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Guardian (For Patients Under 18 years of age
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Guardians Home Number
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Guardians Work Number
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Guardians Home Address
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Guardians City
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Guardians State
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Guardians Zip Code
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Disclaimer
Please note that this online submission process is meant only to be a convenience for our patients. It is not a
substitute for the physician-patient relationship, as a face-to-face visit must be performed to review all data that has
been submitted online.
This online process is not an agreement on our part (AMC) to provide medical treatment.
This online process is not a guarantee of insurance coverage.
All information submitted above is subject to verification.
All data given at this time is not considered accurate/valid until the time the physician and/or office staff has been able
to review this data, in person, with you the patient. Receipt of any patient data without an associated, completed visit
with the doctor will be treated as any other form of unsolicited information.
I understand AMC is not responsible for the data security and data integrity at the time of creation and submission of
this form, as this process is done through a 3rd party with standard, accepted, secure channels of data transfer.
With the electronic submission of this medical information, I certify that the information I have given on these pages is
correct to the best of my knowledge and that I have read and understand the above noted disclaimer. I will not hold my
doctor or any members of his staff responsible for any errors that I may have made in completion of this form.
By clicking on the 'Submit My Information' button below, I have read and understand the above Disclaimer
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Click here to proceed to the Medical Registration,
Part 2 of the two step registration process
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