Member Information and Preferences First Name: Last Name: Gender: Addresses Primary: Secondary: Additional: Contact Preference 212.600.2000 | careteam@atria.org Confidential 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: Date of Birth: Race: Ethnicity: Contact Information Preferred: Cell: Home: Office: Email Address: This information will be used to create your membership account. Please complete as much as you are able to. Phone Text Email Member Registration Form Personal Preferences Shoe Size: Clothing Size: Dietary Restrictions: Emergency Contact Information Contact Name: Contact Telephone: Contact Relationship: 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 Additional Information 212.600.2000 | careteam@atria.org Confidential Preferred Hospital Hospitals & Providers Primary Care Provider Name: Address: Phone Number: Additional Speciality Care Provider Name: Address: Phone: 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.