REGISTRATION FORM SUBMISSION:
- First Name: Patricia
- Last Name: Robinson
- Date of Birth: 06/25/1988
- Social Security: 222-33-4444
- Email: patricia.r@emailprovider.com
- Phone: (424) 555-6789
- Address Line 1: 789 Sunset Boulevard
- Address Line 2: Suite 456
- City: Los Angeles
- State: CA
- ZIP: 90028
- Emergency Contact Name: Robert Robinson
- Emergency Contact Phone: 424-555-9876
- Insurance Provider: HealthCare Plus
- Policy Number: HCP-123456789
- Group Number: GRP-456