Novopatient

Patient register

* marked fields are required before saving the information.

To submit the form press the square button labeled "Save" at the right bottom of the page

Demographic

LAST NAME *

FIRST NAME *

DOB *

SEX/GENDER *

EMAIL *

LANGUAGE *

RACE 1 *

ETHNICITY *

Contact

HOME PHONE

MOBILE *

WORK PHONE

COMMUNICATION PREF

By checking this box, I agree to receive SMS/text messages about appointment reminder, clinic communication, and general clinic updates from Southern Ohio Green Med at the phone number provided above. The SMS frequency may vary. Data rates may apply. Text HELP to for assistance. Reply STOP to opt out of receiving SMS messages, please refer to our privacy policy Privacy policy and security link.

FAX

ADDRESS 1 *

ADDRESS 2

CITY *

STATE *

ZIP *

EMERGENCY CONTACT

NAME

HOMEPHONE

MOBILE

WORKPHONE

ADDRESS 1

ADDRESS 2

CITY

STATE

RELATIONSHIP

USERNAME *

PASSWORD *

CONFIRM PASSWORD *

Type the characters you see in this picture

Characters *

Insurance information ADD

NAME	INSURANCE	POLICY NUMBER	GROUP NUMBER	EFFECTIVE DATE	TERM DATE		ACTION