New Patient Registration Form - Great Lakes Foot and Ankle Center 2025

1. Click ‘Get Form’ to open the New Patient Registration Form in our editor.
2. Begin by filling in your personal details, including your name, date of birth, and contact information. Ensure accuracy as this information is crucial for your medical records.
3. Indicate your gender and race/ethnicity by selecting the appropriate options provided on the form.
4. Complete the insurance section by entering details about your primary and secondary insurance providers, including ID numbers and insured names.
5. In the clinical information section, list any allergies or adverse reactions you may have. This is vital for your safety during treatment.
6. Sign and date the authorization section at the end of the form to grant permission for treatment and information sharing with your insurance company.

Start filling out your New Patient Registration Form today using our platform for a seamless experience!