Can Do – Medica Registration Form

Fax to 952-925-1276 or

email to stippie1@fairview.org

Name:__________________________________________________

(Please Print)

H Phone #: ________________________ W Phone#: _______________________

Alt Phone # _______________________ email ___________________________

Date of Birth: _____________________

Gender Male_______________ Female ________________ Medications? Yes No

Height:____________ Weight:___________ Pre-Exist Hlth Conditions? Yes No

Address: ___________________________________________

City/State/Zip: ________________________________________________________________

Emergency Contact: _____________________________________________

Phone #________________________ Relationship: _________________________________

Medica Insurance ID ________________________

Medica Group ID ___________________________

Provider ______________________________________

Clinic ________________________________________

How did you hear about the program? _________________________________

I am in relatively good health and can tolerate moderate exercise and appropriate dietary interventions Yes______ No______

If no explain:____________________________________________________________

____________________________________________________________________________