<?xml version="1.0" encoding="UTF-8"?>
<patient-registration-form xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="Patient Registration Form.xsd">
	<practice.name></practice.name>
	<patient>
		<data></data>
		<firstname></firstname>
		<lastname></lastname>
		<middlename/>
		<islegalname></islegalname>
		<legalname/>
		<formername/>
		<birthday></birthday>
		<age></age>
		<sex></sex>
		<married>Off</married>
		<parent.guardian.name/>
		<address></address>
		<home.phone></home.phone>
		<cell.phone></cell.phone>
		<social.security.no></social.security.no>
		<occupation></occupation>
	</patient>
	<employer>
		<name></name>
		<address></address>
		<phone></phone>
	</employer>
	<clinicselection>
		<choose></choose>
		<doctorname/>
		<familymembers/>
	</clinicselection>
	<insurance>
		<owner></owner>
		<birthday></birthday>
		<address/>
		<homephone></homephone>
		<patient></patient>
		<coveredbyinsurance></coveredbyinsurance>
		<occupation></occupation>
		<employer>
			<name></name>
			<address></address>
			<phone></phone>
		</employer>
		<primary_insurance>
			<insurance_type></insurance_type>
			<subscriber></subscriber>
			<serial_no></serial_no>
			<birthday></birthday>
			<group_no></group_no>
			<policy_no></policy_no>
			<co_payment></co_payment>
			<patient_relationship>
				<patientrelationship></patientrelationship>
				<otherdesc/>
			</patient_relationship>
		</primary_insurance>
		<secondary_insurance >
			<insurancename/>
			<subscriber/>
			<group_no/>
			<policy_no/>
			<patient_relationship>
				<patientrelationship></patientrelationship>
				<otherdesc/>
			</patient_relationship>
		</secondary_insurance>
	</insurance>
	<emergency_case>
		<targetname></targetname>
		<relationship></relationship>
		<home.phone></home.phone>
		<work.phone></work.phone>
	</emergency_case>
	<emergencyContactForm>
		<patientName></patientName>
		<parent1>
			<name></name>
			<home.phone></home.phone>
			<work.phone></work.phone>
			<address></address>
		</parent1>
		<parent2>
			<name></name>
			<home.phone></home.phone>
			<work.phone></work.phone>
			<address></address>
		</parent2>
		<emergencyContact1>
			<contact></contact>
			<home.phone></home.phone>
			<work.phone></work.phone>
			<address></address>
		</emergencyContact1>
		<emergencyContact2>
			<contact/>
			<home.phone/>
			<work.phone/>
			<address/>
		</emergencyContact2>
		<medicalInfo>
			<preference></preference>
			<physicianName></physicianName>
			<sex></sex>
			<phoneNo></phoneNo>
			<insuranceCompanyName></insuranceCompanyName>
			<policyNo></policyNo>
			<specialConsiderations></specialConsiderations>
		</medicalInfo>
	</emergencyContactForm>
</patient-registration-form>
