New Patient Enrollment Form

BACHTCS Client Enrollment/Update
Name *

First Name Middle Name Last Name
Spouse/Partner (if applicable)

First Name Middle Name Last Name
Preferred Name

First Name Last Name
Spouse/Partner

First Name Last Name
E-mail *
Contact Number: *

Area Code Phone Number
Other Number

Area Code Phone Number
Date of Birth

Month Day Year
Race *
Language *
Gender Identity *
Sexual Orientation *
Marital Status *
Employment Status
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
In case of emergency...
Emergency Contact: *

First Name Last Name
Emergency Contact Number: *

Area Code Phone Number
Relationship *
Contact Number *

Area Code Phone Number
Patient/guardian signed HIPAA NPP Signature *

Clear
PCP Release: *
Should be Empty: