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info@associatedclinical.com

PATIENT PORTAL LOGIN

703 - 569 - 8731

Patient Registration

Identifying Information

Patient's Last name*

Patient's First name*

Social Security Number*

Gender*

Date of Birth*

Month

Day

Year

Address*

Phone number*

Email*

May we contact you / Leave a message?*

Is treatment court ordered?*

Yes

No

Is this your first time with us?

Yes

No

How do you plan on attending?*

In-person

Virtually

Patient's Occupation

Patient's Employer

Patient's level of education*

Spouse's Occupation

Spouse's Employer

Spouse's level of education

If applicable

Primary Medical Care

Name of primary care physician*

Address of primary care physician*

Phone number of primary care physician*

List of medications currently taken

Reason for visit*

Name of person filling out form

Relationship to person filling out form

Emergency contact name*

Emergency contact phone number*

Insurance

Are you currently insured?*

Yes

No

Primary insurance carrier

Primary insurance ID number

Do you currently have more than one insurance?*

Yes

No

Name of secondary insurance carrier

Secondary insurance ID number

Name of secondary policy holder

Signature*

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Today's Date*

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