Adult Registration

New or Existing

New Patient
Existing Patient

Patient Information

First Name *

First Name

Middle Name

Last Name *

Last Name

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Primary Language *

Interpreter Needed

Yes
No

Date of Birth *

Social Security Number

Home Phone

Cell Phone

Other Phone

Preferred method of contact

Phone
MyChart
Email
Mail

Home Phone - Send Reminder?

Send Reminder Calls/Text

Cell Phone - Send Reminder?

Send Reminder Calls/Text

Other Phone - Send Reminder?

Send Reminder Calls/Text

Sex assigned at Birth

Male
Female

Sexual Orientation

Gender Identity

Race (Check all that apply) *

Ethnicity *

Hispanic/Latino
Non-Hispanic/Non-Latino

Is patient employed? (Check any that apply)

Full Time
Part Time
Permanent
Temporary

Employment Status

Agricultural Work (farming, planting, harvesting, raising livestock)

No, I do not primarily work in agriculture
Yes, my primary employment is in agriculture

Employer Name

Employer Phone

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Is patient currently a student?

No
Full-time Student
Part-time Student

Is patient a veteran?

Yes
No

Marital Status

Living Situation

Responsible for Payment (Guarantor)

Name (If self skip below)

Guarantor Address

Address Line 1

Address Line 2

City

State

Zip Code

Guarantor Email Address

Email Address

Guarantor Primary Language

Preferred Language

Guarantor Date of Birth

Date of Birth

Guarantor Social Security Number

Social Security Number

Guarantor Relationship to Patient

Relationship to Patient

Guarantor Home Phone

Home Phone

Guarantor Cell Phone

Cell Phone

Guarantor Other Phone

Other Phone

Emergency Contact (Optional)

Name

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Email Address

Email Address

Emergency Contact Relationship to Patient

Relationship to Patient

Emergency Contact Preferred Language

Preferred Language

Emergency Contact Home Phone

Home Phone

Emergency Contact Cell Phone

Cell Phone

Emergency Contact Other Phone

Other Phone

History Of Applying For Medicaid

Do you have Medicaid or Medicare?

Yes
No

If you do NOT have Medicaid or Medicare, have you ever applied?

Yes
No
N/A

Medical Insurance Information

Do you currently have any medical insurance?

Yes
No

Medical Insurance Name

*If card presented to front desk staff, skip below

Medical Insurance - Policy Number

Policy Number

Medical Insurance - Address

Address

Medical Insurance - Group Number

Group Number

Medical Insurance - Phone Number

Phone Number

Dental Insurance Information

Do you currently have any dental insurance?

Yes
No

Dental Insurance Name

*If card presented to front desk staff, skip below

Address

Dental Insurance - Policy Number

Policy Number

Dental Insurance - Group Number

Group Number

Dental Insurance - Phone Number

Phone Number

Vision Insurance Information

Do you currently have any vision insurance?

Yes
No

Vision Insurance Name

Check this box only if you DECLINE applying for the Sliding Fee Application (discounted rates dependent on income)

Additional File Uploads

Click or drag files to this area to upload. You can upload up to 6 files.

You may upload a picture of your insurance card or photo ID as well as items needed to apply for discounted care.

When form is complete, please click Submit below.