Welcome to Novant Health Go

Online physician clinic preregistration

Please fill out the information below to pre-register for your appointment at a Novant Health physician clinic. Your completed form will be saved as part of your electronic health record, reducing the amount of paperwork you will be asked to fill out in your physician’s practice. Thank you for your cooperation.

Please note: the form below is NOT to be used for hospital pre-registration. Click here for the hospital pre-registration form.

Novant Health Medical Group
Outpatient Information/Consent to Treat - Adults

Patient Information
Date:
Practice name:


Patient Name (Last, First, MI):
   
Referring doctor:
Referring doctor phone #:
Patient Address:
 
Primary doctor:
City/State/Zip:
         
Employer/School:
Home Phone:
Cell Phone:
Work Phone:
Email address:
Social Security #: 
 (Please note that providing your entire Social Security Numbers will greatly assist us in locating your record, however, only the last four digits of your Social Security Number are required.)  
Date of Birth:
 
Age:
Marital Status:
Sex:
Race:
 
Ethnicity:
 
Religion:
 
 
Emergency Contact (Last, First):
 
Relationship:
 
Home Phone:
Cell Phone:

If Responsible party same as patient, click here  to carry over information...
Responsible Party (Last, First):
 
Relationship:
 
Date of Birth:
 
Social Security #:
 
Responsible Party Address:
 
City/State/Zip
         
Phone #:
 

Insurance Information
Primary Insurance:
Employer:
 
Secondary Insurance:
Employer:
Primary Insurance ID #:
 
Primary Insurance Grp #:
 
Secondary Insurance ID #:
Secondary Insurance Grp #:


If primary insured same as patient, click here  to carry over information...


If secondary insured same as patient, click here  to carry over information...
Primary Insured Name (Last,First):
 
Secondary Insured Name (Last, First):
Primary Insured Address:
 
City/State/Zip:
         
Secondary Insured Address:

City/State/Zip:
   
Primary Insured DOB:
 
Primary Social Security #:
 
Secondary Insured DOB:
Secondary Social Security #: