Canby Community Clinic

7601 Canby Ave Ste. 6B
Reseda, CA 91335

Before your visit

Patient Registration Form

Help us prepare your file. Complete the information below and review the authorizations before signing.

Registration is optional and does not confirm an appointment. Fields marked are required to submit this form.

Patient Information

Use your name as it appears on your records.

Last Name

First Name

Middle Initial

Date of Birth

Sex

Marital Status

Contact Information

Please provide at least one phone number . Email is optional.

Address

City

State

Zip Code

Home Phone

Cell Phone

Employment Information

Complete if applicable.

Employer Name

Work Address

City

State

Zip Code

Work Phone

Extension

Occupation

Emergency Contact

Complete if available.

Name

Relationship

Address

Phone Number

Insurance Information

Complete if insured. Leave blank if you do not have insurance.

Primary Insurance

Insurance Company

Last Name

First Name

Relationship to Patient

Policy / Member ID

Group Number

Secondary Insurance

Insurance Company

Last Name

First Name

Relationship to Patient

Policy / Member ID

Group Number

Care Information

Share the details you know.

Primary Care Provider Name

PCP Phone

PCP Fax

Primary Language

Interpreter Services Required

Pharmacy Name and Number

Authorizations

Please read each statement before acknowledging.

Assignment of Benefits and Release of Information

I authorize my insurance benefits to be paid directly to Canby Community Clinic. I understand that I am financially responsible for non-covered services. I authorize the release of medical or other information necessary to process insurance claims on my behalf. A copy of this assignment is as valid as the original.

I acknowledge

Authorization of Treatment

I authorize the physician of record and associates to treat the patient named above.

I acknowledge

Notice of Privacy Practices

I acknowledge that I have been provided a copy of the Notice of Privacy Practices (opens in a new tab).

I acknowledge

Signature

Type your full legal name as your electronic signature. By signing, you agree to the authorizations above.

Patient Signature

Date

Your form will be sent to the clinic office. For assistance, call (818) 674-4414.