Registration Form
For Arkansas clinics. Please fill in the form below and then you will be directed to schedule your initial appointment
Billing Name
*
Prefix
First Name
Last Name
Prefered Name
First Name
Last Name
Social Security Number
Date of Birth
*
-
Month
-
Day
Year
Date
Billing Gender
*
Male
Female
Current Gender
Marital Status
Child
Single
Partnered/Engaged
Married
Separated
Divorced
Widowed
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Spouse/Partner
First Name
Last Name
Employer
Payment Arrangements
None/Self Pay
Commercial
Medicare
Medicaid/Soonercare
Military
Other
Insurance Information
Insurance Company
ID/Policy #
Group #
Copay/Co Insurance Amount
Effective Date
-
Month
-
Day
Year
Date
Front of Insurance Card (If applicable)
Back of Insurance Card (If applicable)
Front of ID
Race
*
America Indian or Alaska Native
Asian
Black or African
Native Hawaiian or Other Pacific Islander
White
Mixed Race
Other
How did you hear about us?
Family/Friend/Word of Mouth
Social Media
Internet Search
Email
Insurance
Print/Newspaper/Magazine
Community Event
School
Referral from provider
Other
Schedule Request
Please complete the information below to be used for your request.
Location
*
Please Select
Little Rock
No longer scheduling in North Litte Rock
Provider
Please Select
Any Provider
Corey Greene, APRN
Kim Hill, APRN
Russell Rooms, APRN
Day of Week
Please Select
Any Day
Monday
Tuesday
Wednesday
Thursday
Friday
Time of Day
Please Select
Any Timer
Morning
Afternoon
Reason for visit
Type of Visit
Primary Care
Gender Affirming Hormone Therapy
HIV Prevention
HIV Treatment
Other
Once you submit the registration form you will be contacted to confirm your appointment details. So you get the most out of your appointment, please complete the intake paperwork and bring it with you. We look forward to providing you with great care!
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