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East Lansing Orthopedic Association
Bone Density Patient Registration
Today's Date
Patient Information
Patient's Legal Last Name
 First Name
 Middle Initial
 Patient Goes By
Birth date
 Age
 Marital Status
 Spouse's Name (if applicable)
Sex:
 Male
Female
Patient Street Address
 City
 State
 Zip Code
Social Security Number
Please provide at time of check-in
Home Phone
May we leave a message at your home number?
Work Phone
May we leave a message at your work number?
Cell Phone
May we leave a message on your cell phone?
Which is your primary number?
May we leave a message with test results and/or medical advice on your primary phone?
Contact Person to Notify in Case of Emergency AND / OR share health / treatment information with:
Relationship to you
Name
Phone number
Employer (indicate if student)
 Occupation
Full time
Part time
Employer's Address
 City
 State
 Zip Code
Parent's Name (if patient a student or under 18)
* If patient under 18 must be accompanied by a parent or guardian
Parent's Address
 City
 State
Zip Code
Parent's Employer
 Parent's Work Phone & ext
Primary Care Physician
 Phone Number
 Fax Number
Referring Physician
 Phone Number
 Fax Number
Insurance Information
Primary Insurance Company Name
 Contract/Claim/ID/Subscriber no.
 Group no.
 Co-payment
Address (on back of card)
 City
 State
 Zip Code
 Phone Number
Patient's relationship to subscriber
 Subscriber's Full Name
 Birth date
 Subscriber's Employer
Contract/Claim/ID/Subscriber no.
Secondary Insurance Name
 Group no.
 Co-payment
Address
 City
 State
 Zip Code
 Phone Number
Patient's Relationship to Subscriber
 Subscriber's Full Name
 Birth date
 Subscriber's employer
Medical History
Height:
 Feet:
 Inches:
 Weight (lbs):
**Current Medications (list drug name, dosage and prescribing doctor):
**If more than 5 medications
please bring in a list at check-in.
Have you had hip surgery?
Have you had back surgery?