New Patient Registration Form
Student Health and Counseling Center Access to SHCC Patient Portal 1007 N. Chandalar Dr.|Fairbanks, AK 99775|907-474-7043
Name
First Name
Last Name
UA ID#
*
Date of Birth
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Mobile Carrier
*
Will you be living in UAF Campus housing, if yes, when? If not, please enter no.
*
Are you currently living in UAF Campus housing ?
Are you a new student needing to upload information? Uploads can be done through our patient portal. web address: https://uafchc.uaf.edu If you are not currently in campus housing, please use this link to supply us with your immunization records: https://form.jotform.com/232359471634157 This form can also be located at our website: www.uaf.edu/chc/forms
Please call us at 907-474-7043, if you need further assistance.
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UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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