West Wichita Family Physicians, P.A.

Patient Registration

Back to Business Office

What type of change do you wish to make?

Patient Only Change

Family Change

New Patient

Basic Information

First Name *

Last Name *

Middle Name

Address *

City *

State *

Zip *

Email *

Home Phone - - *

Cell Phone - -

Work/Other Phone - -

Birthdate / / *

Male

Female

Race

Ethnicity

Preferred Language

Primary Health Insurance Provider

Name of Insurance

Policy/ID #

Group #

Copay

Name of Insured

Birthdate / /

Employer

Date Effective / /

Patients relationship to person who carries insurance

Self

Spouse

Child

Stepchild

Other

Secondary Health Insurance Provider