First Name / Middle Initial /Last Name : * Maiden Name: Date of Birth: Format: mm.dd.yyyy*   S.S.#: Format: xxx-xx-xxxx* Address: * City: * State: * Zip Code:* Patient Phone Number: Format: 111.111.1111*   Patient's Employer Employment Phone Number: Format: 111.111.1111   Employment Type:*

Please Select Full Time Part Time Self Employed Laid Off Not Employed

Marital Status:*

Please Select Single Married Divorced Widowed Separated

Religion and Affiliation:*

Please Select Adventist Anglican Animism Assembly of God Apostolic Atheistic Baptist Baha’i Brith Brethren Buddhist Catholic Charismatic Christian Church of God Community Congregational Disciples of Christ Episcopal Evangelical Greek Orthodox Hindu Jehovah's Witness Jewish Latter Day Saint/Mormon Lutheran Mennonite Methodist Islam Native American Nazarene None Non-denominational Other Pentecostal Presbyterian Protestant Quaker Religious Science Salvation Army Christian Science Seventh Day Adventist Sikh Unitarian

Race:*

Please Select Asian Black Native American/Eskimo/Aleut Other Pacific Islander/Hawaiian Unknown White/Caucasian

First Emergency Contact

First Name: Last Name: Address: City: State: Zip Code: Phone Number: Format: 111.111.1111   Relationship to Patient:

Second Emergency Contact

First Name: Last Name: Address: City: State: Zip Code: Phone Number: Format: 111.111.1111   Relationship to Patient:

PRIMARY INSURANCE

Insurance Company Name:* Address: * City:* State:* Zip Code:* Insurance Phone #: Format: 111.111.1111*   Policy, Member or ID Number:* Group #:* If Medicaid, County issued: Subscriber's Name:* Subscriber's Date of Birth:* Format: mm.dd.yyyy Address: * City:* State:* Zip Code:* Subscriber's Phone #: Format: 111.111.1111*   Employer:* Employment Type:*

Please Select Full Time Part Time

SECONDARY INSURANCE

Insurance Company Name: Address: City: State: Zip Code: Insurance Phone #: Format: 111.111.1111   Policy, Member or ID Number: Group #: If Medicaid, County issued: Subscriber's Name: Subscriber's Date of Birth: Format: mm.dd.yyyy Address: City: State: Zip Code: Subscriber's Phone #: Format: 111.111.1111   Employer: Employment Type:

Please Select Full Time Part Time

Blanchard Valley Health System is now able to provide you easy access to your medical records, test results and online bill payment. To better serve you, would you like to be enrolled into our Patient Portal? *

Please Select Yes No

Preferred Language for yourself:

Please Select Arabic Chinese English French German Hindi Japanese Russian Spanish Vietnamese Other

Do you consider yourself Hispanic/Latino?

Please Select Yes No