Registration Form | Honey Bee Health Collective

Patient Information

Date / Time

Legal Name *

First

Middle

Last

SSN *

Preferred Name or Nickname

Patient Birth Date *

Preferred Pronouns

Preferred Pronoun if not listed above

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Parent(s)/Legal Guardian(s)/Legal Responsible Party

PRIMARY

Name

First

Last

Relationship

Phone

Email Address

Is the address the same as the patient's?

Yes No (if no fill out below)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

I authorized Honey Bee Health Collective to do the following regarding voicemails:

Leave detailed messages Call back only Do not leave message

Appointment reminders?

Yes No

Secondary

Name

First

Last

Relationship

Phone

Email Address

Is the address the same as the patient's?

Yes No (if no fill out below)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

I authorized Honey Bee Health Collective to do the following regarding voicemails:

Leave detailed messages Call back only Do not leave message

Appointment reminders?

Yes No

Income

Anticipated annual household income for the year:

Total # of people living in household, including yourself:

Emergency Contact

Emergency Contact Name

First

Last

Emergency Contact Phone

Insurance Information

If you are not using health insurance, please complete the Application for Sliding Scale to apply for a sliding scale membership fee based on your income.

Insurance carrier:

Policy Number

Group Number

Subscriber Name

Subscriber Birth Date

Subscriber SSN/ID

Subscriber Employer

Medical Information

PCP Name

PCP Phone Number

PCP Fax #

PCP Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Acknowledgement

I have provided accurate information to the best of my knowledge and understand that any information I provide will be used by Honey Bee Health Collective for the sole purpose of providing an accurate diagnosis and to provide effective and adequate treatment.

Signature Field

Clear