Can Do – Preferred One Registration Form

Fax to Can Do Program at 952-925-1276

Name:__________________________________________________

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: _________________________________

Preferred One Insurance ID ________________________

Preferred One Group ID ___________________________

Name of Preferred One Subscriber ______________________ Relationship _______________

Date of Birth of Subscriber ___________________________

Address of Preferred One Subscriber ______________________________

City/State/Zip code ___________________________________

Preferred One Co-pay Amount _______________________

Preferred One Medical Coinsurance Percentage _______________________

Referring Provider ______________________________________

Referring Clinic ________________________________________

How did you hear about the program? _________________________________