Online Patient Registration Form

Employment
Are you currently:
- Employed
- Unemployed
- Student
- Disabled
- Retired
Status:
- Full Time
- Part Time
Place of Employment:
Address of Employment:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employer's Phone Number:
Responsible Party's Name:
First Last
Social Security #:
Address:
Street Address Address Line 2 City State ZIP Code
Home Phone:
Cell Phone:
Email Address:
Responsible Party's Place of Employment:
Employer's Phone Number:
This Clinic has special payment provisions for person who need health care but who are without means of paying for services. Such persons must qualify for assistance by way of an approved Application for Adjusted Fee.
I choose not to report my household status nor household income.
How many people live in your household?*
What is your annual household income?*
Do you have Medical Insurance?*
Name of Health Insurance Company:
Person who holds the Insurance (Subscriber):
First Middle Last
Relationship to Patient:
Insured's Social Security #:
Subscriber's Date of Birth:
Date Format: MM slash DD slash YYYY
Contract #:
Group #:
Second Health Insurance Company:
Person who holds the Insurance (Subscriber):
First Middle Last
Relationship to Patient:
Insured's Social Security #:
Subscriber's Date of Birth:
Date Format: MM slash DD slash YYYY
Contract #:
Group #:
Medicare #:
Medicaid #:
Proof of Insurance
Please upload a copy of your insurance card by taking a picture on your mobile device or by uploading documents from your computer.
Do you currently have an advanced directive or durable power of attorney for healthcare?
If not, would you be interested in talking with Social Services about one?
Consent*
I agree
Authorization for Medical Care: Permission is hereby granted for medical care, as may be advisable or necessary by the attending healthcare provider of this Health Center. I understand that the Health Center will NOT be responsible for hospitalization charges, nor will it be responsible for other services unless specifically authorized. I have read and understand the above consent and accept its terms.
Signature of Patient*
Signature of Parent/Guardian (if under 18)
Date*
Date Format: MM slash DD slash YYYY

Online Patient Registration Form

Step 1 of 2

Patient Information

Employment