Athens Kidney Center

Phone: (706) 227-2110 | (706) KIDNEYS | (706) 543-6397

Physician Referral Form

Registration Form

Welcome to Athens Kidney Center! To save time on your first visit, you can fill out our forms securely online. Step 1 is the New Patient Information form below. Any field with a red star next to it is required information before you can move on to Step 2 (the Family History Form).

* = required field

Patient Information

Last Name*:

First Name*:

Middle Initial:

Address Line 1*:

Address Line 2:

City*:

State*:

Zip Code*:

Phone 1*:

Phone 2:

Social Security Number*:

Martial Status:

Date of Birth*:

Gender*:

Employed*: Yes No

Emergency Contact Information

Last Name*:

First Name*:

Middle Initial:

Address Line 1*:

Address Line 2:

City*:

State*:

Zip Code*:

Phone 1:*:

Phone 2:

Insurance Coverage Information

Main Insurance Provider*:

Policy ID Number*:

Group Number:

Is the patient also the primary policy holder?: Yes No

Do you have a secondary insurance provider?*: Yes No

* = required field.