Pre-Registration

For privacy reasons, please do not email the following form. To provide your information securely, fill out the form below and follow the instructions by completing the form fields, then hit “submit” at the end of the form. Alternatively, you can download, print, complete the forms by hand, then mail or drop off the forms at our clinic, located at: Journey Family Medicine 995 Willagillespie Road, Ste. 300, Eugene, OR 97401. Download and print the pre-registration form here.

Name(Required)

Note: Please use your full legal name.

First Middle Last

Pronouns(Required)

Mailing Address(Required)

Street Address City State ZIP Code

Email(Required)

Cell Phone

Home Phone

Work Phone

Preferred Phone(Required)

Cell Phone

Home Phone

Work Phone

Date of Birth(Required)

Current Medications

(lnclude birth control pills and non-prescriptive items such as vitamins, aspirin, herbs, etc.)

Select the plus sign to add additional medications.

Medication

Dose

Time/Day

Primary Insurance Information

Insurance Company Name

Identification Number

Group Number

Name of Insured Party

Relationship to Patient

Insured Party Date of Birth

Sex (Required by insurance for billing purposes)

Do you have secondary insurance?(Required)

Yes

Secondary Insurance Information

Insurance Company Name

Identification Number

Group Number

Name of Insured Party

Relationship to Patient

Insured Party Date of Birth

Sex (Required by insurance for billing purposes)

Signature

Signature(Required)

Use your mouse (desktop) or finger (mobile) to write your signature. Select the circle arrows in lower right corner to erase signature.

Date(Required)

CAPTCHA