Patient Information

 
 

Sex


 
 
 
 
 

Phone Number Type


 

Is the Patient currently employed?


 

(If yes) Employer Name and Address

 

Visit Information

 
 

Next of Kin Information

 
 
 
 
 

Emergency Contact

 
 
 
 
 

Insurance Information

Do you currently have insurance?


 

Responsible Party Information

Is the Responsible Party the same as the patient?


Is there another Responsible Party?


Please bring any paperwork, insurance card, photo ID and payment. If you have questions, please call 660-827-7900.
 

Other Information

Are you a spouse or dependant of a Bothwell Regional Health Center employee?