Patient Information




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?