Patient Registration Form

Section 1: Personal Information

Full Legal Name *

Date of Birth *

Social Security Number *

Sex Assigned at Birth *

Preferred Pronouns

Home Address *

Primary Phone *

OK to leave voicemail

Alternate Phone

Email Address

Marital Status

Preferred Language

Section 2: Emergency Contact

Contact Name *

Relationship *

Phone Number *

Alternate Phone

Section 3: Insurance Information

Primary Insurance

Insurance Company Name *

Policy/Member ID *

Group Number

Policy Holder Name

Relationship to Patient

Insurance Phone Number

Secondary Insurance (if applicable)

Insurance Company Name

Policy/Member ID

Group Number

Please bring copies of your insurance cards (front and back) to your first appointment.

Section 4: Medical History & Providers

Section 5: Social History & Lifestyle

Section 6: Current Wound Information

Where is your wound located? *

How long have you had this wound? *

How did the wound start?

Have you received treatment for this wound before?

Current Symptoms (check all that apply)

Pain Drainage Odor Redness/Swelling Bleeding Getting worse

Section 7: Consent & Acknowledgments

Authorization for Treatment

I authorize Healix360 Mobile Wound Care Specialists and its healthcare providers to examine, diagnose, and provide treatment for my condition. I understand that I have the right to refuse any specific treatment or procedure.

I agree to the above authorization

Assignment of Insurance Benefits

I authorize payment of medical benefits to Healix360 for services rendered. I understand that I am financially responsible for any charges not covered by my insurance.

I agree to assignment of benefits

Financial Responsibility

I understand that I am financially responsible for all charges whether or not paid by insurance. I agree to pay all deductibles, copayments, and non-covered services at the time of service or upon receipt of a statement.

I understand my financial responsibility

Release of Medical Records

I authorize Healix360 to release my medical information to my insurance companies, other healthcare providers involved in my care, and as required by law.

I authorize release of medical information

HIPAA Notice

I acknowledge that I have received and reviewed the Notice of Privacy Practices. I understand how my health information may be used and disclosed.

I acknowledge receipt of HIPAA notice

View HIPAA Consent Form

Patient/Guardian Certification

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that providing false information may result in denial of services.

I certify this information is accurate

Patient/Guardian Signature *

Signature will be obtained at appointment

Date *