New Patient Registration PhoneThis field is for validation purposes and should be left unchanged.NEW PATIENT REGISTRATIONCurrent PCP: Please select your HFM location: (REQUIRED)* Clayton Four Oaks Riverwood Which Clayton Provider do you see? (REQUIRED)* Dr. Williams Dr. Harris Dr. Kahn Dr. McGill Dr. Selak Dr. Norris Megan Wester, PA Brittany McCall, FNP-C Morgan Smith, FNP-C Deborah Roberson, FNP-C Which Four Oaks Provider do you see? (REQUIRED)* Dr. Olivia Johnson Hannah Brame, PA-C Which Riverwood Provider do you see? (REQUIRED)* Dr. Zenchenko (Dr. Z) Caroline Lewis, PA-C Patient InformationLegal Name:Suffix:SSN:Date of Birth:Email:Home Address:City State Zip:Mailing Address:City State Zip:Home Number:Cell Number:Work Number: Marital Status: Single Married Divorced Widowed Gender: Male Female Race: White/Caucasion Black/African American Other First language: English Spanish Other Ethnicity: Hispanic Non-Hispanic Emergency Contact - Who may we contact in case of an emergency?Name:Relationship to Patient:Home Number:Cell Number:Work Number:Privacy Information – HIPAA – Communicating with your Family, Friends, or CaregiversI authorize Horizon Family Medicine to contact me and/or to leave telephone messages in the following ways: Home Phone: Home Phone: Work Phone: Cell Phone: Email: I authorize Horizon Family Medicine to release my medical information to the named persons listed below: Spouse: Phone Number: Relative: Phone Number: Other: Phone Number: I DO NOT wish to release my health information to anyone besides myself. Insurance InformationPrimary InsuranceCompany:Policy #:Group #:Policy Holder's Name:Policy Holder's DOB:Relationship to Patient:Secondary InsuranceCompany:Policy #:Group #:Policy Holder's Name:Policy Holder's DOB:Relationship to Patient:Read and Sign BelowI certify that the information provided is correct and complete to the best of my knowledge. Signature of Patient (or Legal Guardian):*Date:*VACCINATION POLICY At Horizon Family Medicine, we are committed to providing the highest standard of care to all our patients. Based on evidence-based guidelines and recommendations from the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and other public health authorities, we require that all patients follow the routine childhood immunization schedule. OUR POLICY We do not accept patients who are unvaccinated or whose parents/guardians choose to decline routine childhood immunizations without a valid medical contraindication. This policy is in place to: Protect the health and safety of all children and families who visit our practice. Prevent the spread of vaccine-preventable diseases. Support community immunity, especially for those who are too young or medically unable to be vaccinated. We recognize that parents and guardians have the right to make medical decisions for their children. However, we believe that not vaccinating poses a risk to other patients and staff in our practice and contradicts our commitment to public health and safety. EXEMPTIONS Only documented medical exemptions signed by a licensed medical provider will be considered on a case-by-case basis. We do not accept philosophical or religious exemptions. AGREEMENT * *By signing below, you acknowledge that you have read, understand, and agree to comply with our practice's vaccination policy. You also understand that failure to comply may result in discharge from the practice. Parent/Guardian Name: Child's Name(s):Date:* Signature:* This field is hidden when viewing the form