REGISTRATION FORM
DOCKET NUMBER:
RECEPTIONIST:
SERVICES OFFERED (please check service required)
☐General Practioner
☐Bariatric Surgery
☐Cosmetic Medicine
☐Internal Medicine/Nephrology
☐Obstetrics/Gynaecology
☐Urgent Care
☐ Cardiology – Adult/Paediatric
☐Dermatology/Veneorology
☐Neurology
☐Paediatric/Neonatology
Have you seen any other physicians at TrinCay? ☐Yes
☐Anaesthesiology/Pain Management
☐Cardiothoracic Surgeon
☐General Surgery
☐Neurosurgeon
☐Psychiatry
☐No
HOW DID YOU HEAR ABOUT US?
☐Yellow Pages
☐Radio – X107.1FM
☐Radio – 101.1FM ICCI Radio
☐Patient Referral
☐New Resident
☐Radio – Hot 104.1FM
☐Newspaper
☐Word of Mouth
ARE YOU VISITING THE CAYMAN ISLANDS AS A TOURIST?
☐Word of Mouth
☐Radio – KISS 106.1FM
☐Post Office Flyer
☐Physician Referral
☐YES
☐Website
☐Radio – 96.5FM CayRock
☐TV
☐ NO
PATIENT INFORMATION
PLEASE COMPLETE DATA AS NEEDED: (INDICATE N/A IF NOT AVAILABLE)
FIRST NAME:
MIDDLE INITIAL:
DATE OF BIRTH: MONTH:
LAST NAME:
DAY:
YEAR:
SEX: ☐MALE ☐FEMALE
PAEDIATRIC PATIENT
☐YES
☐ NO
PARENTS NAME (PAEDIATRIC PATIENTS ONLY)
FIRST NAME:
LAST NAME:
RELATIONSHIP:
FIRST NAME:
LAST NAME:
RELATIONSHIP:
CAYMAN ISLANDS ADDRESS:
MAILING ADDRESS:
P.O. BOX NO.:
P.O. BOX LOCATION:
POSTAL CODE:
PHYSICAL ADDRESS:
STREET:
APT:
DISTRICT:
CONTACT:
CELL PHONE:
HOME:
EMERGENCY CONTACT NAME/NUMBER:
WORK/DIRECT:
EMAIL:
EXT.:
INTERNATIONAL MAILING ADDRESS
HOTEL/CONDO:
STREET:
CITY:
STATE:
ZIP:
INTERNATIONAL CELL PHONE:
EMERGENCY CONTACT NAME/NUMBER:
INSURANCE INFORMATION
DOES THE PATIENT HAVE MEDICAL INSURANCE?
IS THE PATIENT THE GUARANTOR?
IS THE PATIENT SELF PAY?
☐YES
☐YES
☐YES
☐ NO
☐ NO
☐ NO
INSURANCE COMPANY:
(INTERNATIONAL HEALTH INSURANCE HOLDER WILL NEED TO PAY UPFRONT)
ID/CERTIFICATE NUMBER:
GROUP NUMBER:
NAME OF PRIMARY HOLDER (FILL-OUT IF DEPENDENT):
DATE OF BIRTH OF PRIMARY HOLDER: MONTH:
DAY:
YEAR:
EMPLOYER:
EMPLOYER ADDRESS/NUMBER:
ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent/guarantor) have insurance coverage with
(name of insurance company) and assign directly to TrinCay Medical Centre & Urgent Care and/or its physicians all insurance benefits, if any,
otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by the
insurance. I hereby authorize TrinCay Medical Centre & Urgent Care and/or its physicians to release all information necessary to ensure the
payment of benefits. I authorize the use of this signature on all insurance submissions.
SIGNATURE
RELATIONSHIP TO GUARANTOR/PRIMARY HOLDER
DATE (MONTH/DAY/YEAR)