Emergency: 119
AMDA-IMIC

US Medical Forms · 中文

患者登记表

⚠ 这是参考翻译，帮助您了解典型表格内容。这不是官方文件。您的医疗提供者的实际表格可能有所不同——请务必签署提供者自己的版本。
When you receive this form 在与新提供者的首次预约前，通常以邮件、电子邮件或在候诊室发放。部分诊所提供在线患者门户，可在到达前填写。
What to bring or have ready 您的健康保险卡、政府颁发的带照片的身份证件（如驾照或护照）、当前药物及剂量清单，以及紧急联系人的姓名和电话号码。

个人信息 / Personal Information

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Legal Name (Last, First, Middle) 法定姓名（姓、名、中间名） Your full legal name exactly as it appears on your government-issued ID. Must match your insurance records. Include your middle initial or full middle name if the form provides space. 您的法定全名，与政府颁发的身份证件完全一致。必须与保险记录匹配。如表格有空间，请填写中间名首字母或完整中间名。
Date of Birth 出生日期 Your birth date in the format the form requests, usually MM/DD/YYYY in the US. Used to verify your identity and match your insurance records. 按表格要求的格式填写出生日期，美国通常为月/日/年（MM/DD/YYYY）。用于核实身份并与保险记录匹配。
Sex / Gender Identity 出生性别 / 性别认同 Some forms ask for sex assigned at birth (male/female) for clinical and insurance purposes. Many providers also offer a separate field for gender identity. Both help clinicians provide appropriate care. 部分表格出于临床和保险目的，询问出生时分配的性别（男/女）。许多提供者还提供单独的性别认同字段。两者都有助于临床医生提供适当的护理。
Social Security Number (Last 4 Digits, Optional) 社会安全号码（后四位，选填） Some providers ask for the last four digits of your SSN to help match your records and process insurance claims. You are generally not required to provide this if you are uncomfortable. 部分提供者会要求社会安全号码后四位，以帮助匹配记录和处理保险索赔。如果您不愿意提供，通常不是必填项。

联系信息 / Contact Information

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Home Address 家庭地址 Your current mailing address including street number and name, apartment number if applicable, city, state, and ZIP code. Used to send appointment reminders and billing statements. 您当前的邮寄地址，包括门牌号和街道名称、公寓号码（如适用）、城市、州和邮政编码。用于发送预约提醒和账单。
Phone Number 电话号码 Your best phone number including area code. Many forms offer separate fields for home, cell, and work. Indicate which number to use and whether the office may leave a voicemail message. 您最常用的电话号码，包括区号。许多表格提供家庭、手机和工作号码的单独字段。请注明应使用哪个号码，以及是否可以留下语音信息。
Email Address 电子邮件地址 Your email address if you have one. Providers use email to send appointment confirmations, lab results, and billing notices. Usually optional, but required to access most patient portal services. 您的电子邮件地址（如有）。提供者使用电子邮件发送预约确认、检验结果和账单通知。通常为选填，但访问大多数患者门户服务时需要。

紧急联系人 / Emergency Contact

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Emergency Contact Full Name 紧急联系人全名 The person the provider should contact if you are unconscious or unable to make decisions. This person is not automatically granted medical decision-making authority — they are simply notified in an emergency. 如果您意识不清或无法做出决定，提供者应联系的人员姓名。此人不会自动获得医疗决策权——他们只是在紧急情况下被通知。
Relationship to Patient 与患者的关系 How the emergency contact is related to you — for example, spouse, parent, child, sibling, partner, or friend. Helps staff communicate appropriately with that person. 紧急联系人与您的关系——例如：配偶、父母、子女、兄弟姐妹、伴侣或朋友。帮助工作人员与该人进行适当沟通。
Emergency Contact Phone Number 紧急联系人电话号码 The best phone number to reach your emergency contact, including area code. Confirm this number is current and let the contact know they are listed. 联系紧急联系人的最佳电话号码，包括区号。请确认此号码是最新的，并告知联系人已将其登记。

保险信息 / Insurance Information

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Insurance Carrier Name 保险公司名称 The name of your health insurance company exactly as printed on your insurance card — for example, Blue Cross Blue Shield, Aetna, United Healthcare, or Medicaid/Medicare. 您的健康保险公司名称，与保险卡上印刷的完全一致——例如：蓝十字蓝盾、安泰、联合医疗、医疗补助/医疗保险。
Member / Insurance ID Number 成员/保险ID号码 The unique ID number on your insurance card that identifies you in your insurer's system. May be labeled 'Member ID', 'ID Number', or 'Subscriber ID'. Copy it exactly, including any letters. 保险卡上的唯一ID号码，用于在保险公司系统中识别您。可能标注为「会员ID」、「ID号码」或「订户ID」。请原样复制，包括任何字母。
Group Number 团体编号 A number linking you to an employer plan or group policy, often labeled 'Group' or 'Group No.' on your card. If you purchased coverage on your own and have no group number, write 'N/A' or leave blank. 将您与雇主计划或团体保险联系起来的号码，通常标注为「团体」或「团体编号」。如果您自购保险且没有团体编号，请写「不适用」或留空。
Primary Insured Name (If Different from Patient) 主要被保险人姓名（如与患者不同） If your insurance is under someone else's name — such as a parent, spouse, or domestic partner — write that person's full legal name and your relationship to them. Leave blank if you are the primary insured. 如果您的保险以他人名义购买（如父母、配偶或伴侣），请填写该人的法定全名及您与其的关系。如果您是主要被保险人，请留空。

语言和口译偏好 / Language and Interpreter Preferences

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Preferred Language for Medical Care 医疗护理首选语言 The language you feel most comfortable using to discuss your health. Under federal law, providers receiving federal funding must offer language assistance at no charge to patients with limited English proficiency. 您最能舒适地讨论健康状况的语言。根据联邦法律，接受联邦资金的提供者必须向英语能力有限的患者免费提供语言服务。
Interpreter Needed? (Yes / No) 是否需要口译员？（是 / 否） If you need a qualified interpreter to communicate with your provider, mark 'Yes'. Under federal civil rights law, covered providers must arrange a qualified interpreter at no cost to you. Family members should not be asked to interpret medical information on your behalf. 如果您需要合格口译员与提供者沟通，请标注「是」。根据联邦民权法，受覆盖的提供者必须免费安排合格的口译员。不应要求家庭成员代您口译医疗信息。

Related guides

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Sources

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Last reviewed: September 2026