McLaren-Greater Lansing Sports Medicine Patient Registration Form
This is a secure site.  Please complete the information below.

* Indicates required information

Last Name:

First Name: 

Middle Initial: 

Prior Name:

Address: *

City: *

Zip Code: *

County: *

Last 4 digits of Social Security #: * 

Home Phone: *

Cell Phone:



Marital Status:

Birth Date: *


Were you referred or seen by an Athletic Trainer?

Have you been seen at the Saturday Injury Clinic?

Employment Status: *

If Retired, date of retirement:


Work Phone: 

Address of employer:

City of employer: 

Zip Code of employer: 

These next 10 questions are insurance information
Insurance Primary:


Birth Date:

Subscriber relationship to patient:

Subscriber's Employer:

Insurance Secondary:


Birth Date:

Subscriber relationship to patient:

Subscriber's Employer:

The information below will assist us in your care and in any communications with you
, while protecting your confidentiality. Please review and check 'Yes' or fill in a name
if approved. You may amend this statement at any time. 

Leave message at my home and-or answering machine regarding appointment scheduling. * 

Leave message at my home requesting a return call. *

Leave message at my office requesting a return call. *

Leave a message at my office voice mail regarding my health care. * 

It is ok to speak with ______ regarding my treatment (specify name if approved)

If you are a Medicare Recipient, please answer the rest of the questions.
They are required by Medicare:

Are you eligible for Medicare based upon (check all that apply) 

Are you receiving Black Lung Benefits?

If you are receiving Black Lung Benefits, when did the benefits begin?
Have you participated in a government medical research program, in which services at this facility are being paid for?

If you are a Veteran, has Veteran Affairs authorized/agreed to pay for care at this facility?

Does your group insurance employer employ?

Which Surgeon?

How did you hear from us?

If retired, your retirement date:

Has your spouse ever worked outside the home?

Is your spouse retired?

Retirement date of spouse: