Patient RegistrationWe are here for our patients. Reach out by any method listed here 847-920-0902 Patient DataThe Hansa Medical Groupe consent packet is for your review; however, all we need on the form below (pages 2 and 3 of the packet) completely filled. If something does not apply, please mark it N/A.Patient's Full Name *Practice Start Date *Community Name (if applicable)Community Type *Independent LivingAssisted LivingMemory CareStreet Address *Apartment, suite, etcCityState/ProvinceCell Phone *Home PhoneReferral SourceReferral Name *Social Security Number *Marital Status *SingleMarriedWidowedDivorcedBirthdate *Age *Sex *MaleFemaleSpouse’s Name (if applicable)Spouse's Phone *Power of Attorney (if applicable)Power of Attorney Phone *Insurance InformationPrimary Insurance *Group/Policy Number *Secondary InsuranceGroup/Policy NumberPower of Attorney Contact InformationName *Relationship *Cell Phone *Home PhonePharmacy NamePharmacy Phone NumberMedication List *Medical Conditions *HANSA MEDICAL GROUPE FULL CONSENTMy signature below will be applied to all consent pages in this packet except for the Advanced Beneficiary Notice or ABN. You may be asked to sign the ABN in the future based on specific non-payment related circumstances. By signing below, I am consenting to have read through and understand all aspects of the Hansa Medical Groupe consent packet and the separate practice packet. I understand and agree to all parts of the Hansa Medical Groupe consent packet and responsibilities as a patient, for any primary care medical service, back-up physician medical services, any specialty care, Chronic Care Mgt, Remote Patient Monitoring, Principal Care Management Service, and/or any telehealth services provided by Hansa Medical Groupe. This includes the Credit Card Authorization, unless specified otherwise.Please check Service type *PCPBackup PCPPatient's Full Name *Birthdate *Building Name *Apartment/Suite Number *Resident Cell Phone Number *Building Phone Number *Power of Attorney Name *Power of Attorney Phone Number *Email Address *Signature *Start signing your signature hereYour browser does not support e-Signature field.Submit Form The HMG Consent Packet The HMG Practice Packet includes all of the forms necessary to become a patient of Hansa Medical Groupe HMG Locations