Exit Patient Registration Form NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information. Question Title * 1. Patient name Question Title * 2. Email Question Title * 3. Phone number Question Title * 4. Address Question Title * 5. Date of Birth Date Date Question Title * 6. Gender Identity Man Woman Non-binary Prefer to self-describe (please specify) Question Title * 7. Primary Care Physician (PCP) Question Title * 8. Primary Care Physician (PCP) phone number Health History Question Title * 9. Currently taking any medications? Yes No Question Title * 10. Reason for patient registration Question Title * 11. Preferred Pharmacy Question Title * 12. Pharmacy Phone Number Emergency Contact Question Title * 13. Emergency Contact Question Title * 14. Relationship Question Title * 15. Emergency Contact Phone Number Insurance Information Question Title * 16. Insurance Company Question Title * 17. Insurance ID Question Title * 18. Policy Holder's Name Done