Academy Park Family Practice

Registration form

Last name *

First Name *

Middle name or initial

Date of Birth *

Street Address 1 *

Street Address 2

City *

State *

Zip code *

used to communicate through the portal

Cel phone or home phone *

Work phone

Additional cel phone

Insurance company *

enter NONE if self-pay<br/>

Insurance ID number *

Enter NONE if none

Insurance group number *

Are you the primary insured? *

Yes

Maybe

If not, who is? *

Myself

Spouse

Parent

Other

Name of insured?

Insured DOB

* Required field