NextGen HealthCare Group

New Patient Registration

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Personal

Contact

Employment

Pharmacy

Insurance

Medical

Documents

Preferences

Review

Consent

Personal Information

First Name*

Middle Name

Last Name*

Date of Birth*

Gender*

Marital Status*

Preferred Pronouns

Contact & Address

Email Address*

Mobile*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Mailing address is the same as physical address

Employment Details

Employment Status*

Pharmacy Details

Preferred Pharmacy Name*

Pharmacy Location (Zip Code)*

Insurance Details

Provider Name*

Plan Type*

Policy Number*

Group ID*

Medical History

Known Allergies*

Current Medications*

Past Surgeries

Document Upload

Identity Verification (ID Card)*

Upload a file

or drag and drop

PNG, JPG, PDF up to 10MB

Insurance Card (Front & Back)*

Upload a file

or drag and drop

PNG, JPG, PDF up to 10MB

Communication Preferences

Preferred Language*

Appointment Reminders*

Preferred Contact Method*

Review Your Information

Please review all the information you have provided. Click on any section to go back and edit.

Consent

Consent Forms*

I consent to treatment and acknowledge the financial responsibility.

I acknowledge receipt of the HIPAA Notice of Privacy Practices.

I authorize the release of my information for treatment and payment.

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Patient Management System

New Patient Registration

Personal Information

Contact & Address

Mailing Address

Employment Details

Pharmacy Details

Insurance Details

Medical History

Document Upload

Communication Preferences

Review Your Information

Consent

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