PATIENT REGISTRATION AND POLICIES
We are pleased to welcome you as a patient. At CWPS, we always strive to provide the best medical care for your feet and ankles, and responsive, compassionate patient care. Your privacy and convenience are important to us. Thank you for choosing CWPS.
For your convenience, print and fill out the patient registration form below and bring it in to our office to save time on your first visit.
CENTRAL WASHINGTON PODIATRY SERVICE
We are pleased to welcome you as a patient. At CWPS, we always strive to provide the best medical care for your feet and ankles, and responsive, compassionate patient care. Your privacy and convenience are important to us. Thank you for choosing CWPS.
For your convenience, print and fill out the patient registration form below and bring it in to our office to save time on your first visit.
Doctor/Location
Donald W. Orminski, D.P.M
Yakima Sunnyside
Patient Information
Today's Date _________________ Social Security # _________________
Last Name ___________________ First Name ___________________ Middle Initial ____
Address ___________________________________________________________________
City/State _____________________________________ Zip Code ___________________
Birthdate ________________________________ Age _______ Sex Male Female
Status S M W D
Home Phone ___________________ Work Phone ___________________ Extension _______
Patient's Employer _____________________________________________________________
Spouse's Name _____________________________ Social Security # __________________
Responsible Party for Bill Patient Spouse Father Mother
If Child (Dependent)
Father's Name ______________________________ Social Security # _________________
Father's Address _________________________________ Phone # ____________________
Father's Employer ______________________________________________________________
Mother's Name ______________________________ Social Security # _________________
Mother's Address _________________________________ Phone # ____________________
Mother's Employer _____________________________________________________________
Legal guardian ____________________________________ Phone # ___________________
Primary Doctor ________________________ Referring Doctor ________________________
Primary Insurance ______________________________________________________________
Subscriber ____________________ ID# ___________________ Group# _________________
Secondary Insurance ____________________________________________________________
Subscriber ____________________ ID# ___________________ Group# _________________
Name of friend or relative who is not currently residing at your residence and phone # for emergency:
________________________________________________________________________________
Whom may we thank for suggesting that you come to our office? Name and address below:
________________________________________________________________________________
I authorize release of medical information necessary to process claim. I authorize payment of medical benefits to Dr. Orminski:
________________________________________________________________________________