Atria Registration Form.pdf -

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Member Registration Form This information will be used to create your membership account. Please complete as much as you are able to. Member Information and Preferences First Name: Date of Birth: Last Name: Race: Gender: Ethnicity: Addresses Contact Information Primary: Preferred: Cell: Secondary: Home: Office: Additional: Email Address: Contact Preference Phone Text Email Authorized Individuals Individuals authorized to make changes to your account, schedule appointments or coordinate on your behalf. No medical records will be disclosed to these individuals. Name: Name: Name: Emergency Contact Information Personal Preferences Contact Name: Shoe Size: Contact Telephone: Clothing Size: Contact Relationship: Dietary Restrictions: 212.600.2000 | [email protected] Confidential Medical History This information will be used to support your onboarding process, as we create a single, comprehensive medical record. Please complete as much as you are able to, but know we will capture additional information during the onboarding process. Hospitals & Providers Primary Care Provider Additional Speciality Care Provider Name: Name: Address: Address: Phone Number: Phone: Preferred Hospital Additional Information Please submit the following information Government-issued Photo ID Medical Insurance Card(s): Please note, we are requesting this information to coordinate care with external parters and our pharmacy. At this time, Atria does not accept insurance List of names & phone numbers of your current or past doctors to gather health history 212.600.2000 | [email protected] Confidential