​​​Online Registration Form

 

Appointment — Step 1 of 6

Is your appointment tomorrow?
Appointment Time

Your Information — Step 2 of 6

First Name
Last Name
Phone (xxx-xxx-xxxx)
E-mail
Relationship to Patient

Patient's Information — Step 3 of 6

Background

First Name
Last Name
Is there another name (nickname) the patient prefers?
Date of Birth (xx/xx/xxxx)
Hospital where patient was born (If less than one year old)
City where patient was born
State where patient was born
Sex
Pronoun
Do you consider that patient Hispanic/Latino?
Race Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Unknown
Declined

Patient's Home Address

Address Line 1
Address Line 2
City
State
Postal Code
Phone (xxx-xxx-xxxx)

Primary Care Physician

(the doctor you visit for immunization, school physicals, etc.)

First Name
Last Name
Phone (xxx-xxx-xxxx)

Contacts — Step 4 of 6

Please fill this section out for any adults that are involved in your child's care

Contact A

First Name
Last Name
Date of Birth (xx/xx/xxxx)
Relationship to Patient
Contact
Social Security Number
If you are the legal guardian, do you have documentation that identifies you as the legal guardian?
Address Line 1
Address Line 2
City
State
Postal Code
Phone (xxx-xxx-xxxx)

Contact B

First Name
Last Name
Date of Birth (xx/xx/xxxx)
Relationship to Patient
Contact
Social Security Number
If you are the legal guardian, do you have documentation that identifies you as the legal guardian?
Address Line 1
Address Line 2
City
State
Postal Code
Phone (xxx-xxx-xxxx)

Insurance — Step 5 of 6

Primary Insurance Policy

Type of Insurance

Review & Submit — Step 6 of 6

Appointment

Make Changes
Appointment Date

Your Information

Make Changes
Name
Phone
Relationship to Patient
E-mail

Patient's Information

Make Changes
Name
Nickname
Phone
Do you consider that patient Hispanic/Latino?
Date of Birth (xx/xx/xxxx)
Race
Sex
Pronoun
Patient's City, State, and Hospital
Address
Physician's Name
Physician's Phone

Contacts

Make Changes
Contact A's Name
Contact A's Date of Birth
Relationship to Patient
SSN
Contact A's Phone
Contact A's Address

Insurance

Make Changes
Type of Insurance