Patient Registration – Baylor Frisco

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Please choose the type of registration: *

Labor & Delivery
Surgery

Patient Information

Patient's Name *

First

Middle

Last

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Patient's Date of Birth *//

Patient's Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Patient's Phone Number: *

Patient's Marital Status *

Race *

Are you of hispanic origin? *

Yes
No

Patient's Email Address *

Social Security Number *

Patient's Religious Preference: *

Patient Employment

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Is the patient employed? *

Yes
No

Patient's Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Patient's Employment Status

Next of Kin

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Patient's Next of Kin: *

Does Patient's Next of Kin have a different address than the patient? *

Yes
No

Next of Kin Address

Address Line 1

Address Line 2

City

State

Zip Code

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Next of Kin Phone Number: *

Next of Kin relationship to patient: *

Is your person to notify the same as your Next of Kin? *

Yes
No

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Person to Notify Address:

Address Line 1

Address Line 2

City

State

Zip Code

Person to Notify Phone Number:

Guarantor

Is the patient a minor? *

Yes
No

Guarantor Name:

First

Last

Guarantor Date of Birth://

Guarantor Address:

Address Line 1

Address Line 2

City

State

Zip Code

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Gurantor Employer Name

Guarantor Employer Address:

Address Line 1

Address Line 2

City

State

Zip Code

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Guarantor Employment Status:

Insurance Provider Information:

Insurance Provider *

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Insurance ID #: *

Insurance Group #: *

Policy Holder Name: *

First

Last

Does Policy Holder have a different address to the patient? *

Yes
No

Policy Holder Address:

Address Line 1

Address Line 2

City

State

Zip Code

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Policy Holder Date of Birth *

Policy Holder Social Security: *

Policy Holder Relationship to Patient: *

Is the Policy Holder Employer Different to the Patient Employer? *

Yes
No

Policy Holder Employer Name:

Policy Holder Employer Address:

Address Line 1

Address Line 2

City

State

Zip Code

Is there a Secondary Insurance Provider? *

Yes
No

Secondary Insurance Provider:

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Secondary Insurance Policy Holder Name:

First

Last

Secondary Policy Holder Address:

Address Line 1

Address Line 2

City

State

Zip Code

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Secondary Policy Holder Employer:

Secondary Policy Holder Employer Address:

Address Line 1

Address Line 2

City

State

Zip Code

Baby's Insurance

Is the baby's insurance provider different to the patient's?

Yes
No

Baby's Insurance Provider

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Baby's Insurance Policy Holder Name

First

Last

Baby's Insurance Policy Holder Address:

Address Line 1

Address Line 2

City

State

Zip Code

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Baby's Insurance Policy Holder Relationship to Patient:

Additional Patient Information

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Do you have any sensory or physical impairments? *

Yes
No

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Recognizing that text message communication is not a completely secure method of communication, do you consent to receiving text messages regarding your account? *

Primary Care Physician

Primary Care Physician *

Primary Care Physician Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Care Physician Phone Number: *

Due Date *//

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Would you like to enroll in CommonWell Health Information Exchange? *

Yes
No

CommonWell is a not-for-profit trade association that breaks down technological and process barriers that inhibit effective health data exchange. The organization works to drive new innovations and to make health data more accessible with the aim of improving health outcomes. CommonWell works to help patients and providers get better access to health records and better coordinate care.

Driver's License Number (for CommonWell Registration):

In the last 14 days have you traveled outside of the United States? *

In the last 14 days, have you been asked by a healthcare provider to self-quarantine or had close contact with anyone while they were quarantined? *

In the last 12 months, did you stay overnight in a healthcare facility outside of the United States? *

Do you have fever, cough, or shortness of breath? *

In addition to fever, cough, and shortness of breath, do you have night sweats or unexplained weight loss? *

Do you have at least TWO of these symptoms? Fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or NEW loss of taste or smell? *

Have you or anyone you had close contact with been diagnosed with a laboratory confirmed case of:

Your Signature *

Please sign to confirm the information provided for registration.