Patient Sleep Survey | Serene Sleep Center, Flint, MI

Patient Registration Form

Contact Us

Referring doctor:

Name:

DOB:

Address:

City:

Zip:

Phone:

SSN:

Race:

Sex:

Male

Female

Have you ever had hepatitis?:

Yes

Do you have an advance directive (living will)?

Yes

Would you like information about advanced directives?

Yes

PRIMARY Insurance:

Contract/ID No. :

Group No. :

Subscriber Name:

Relationship to you:

Employer:

Phone:

SECONDARY Insurance:

Contract/ID No. :

Group No. :

Subscriber Name:

Relationship to you:

Employer:

Phone:

If minor, parent information:

If minor, parent information:

Parent name:

DOB:

SSN:

Address(if different):

Phone:

Employer:

Employer phone:

Next of kin or contact person(s):

Next of kin or contact person(s):

Emergency Contact Name:

Phone:

Relationship:

Address:

City:

Zip:

Name:

Phone:

Relationship:

Address:

City:

Zip:

Patient Registration Form

Contact Us

Serene Sleep Center

1125 S. Linden Road, Suite 270

Flint, MI 48532

Phone: 810-600-7000

Fax: 810-422-9131