Diversity Family Health Registration

Registration Form

To become a patient with Diversity Family Health please complete the form below
Status

RecievedBookedCancelled
Billing Name*

First NameLast Name
Prefered Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Billing Gender*
Current Gender
Marital Status

ChildSinglePartnered/EngagedMarriedSeparatedDivorcedWidowed
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Spouse/Partner

First NameLast Name
Race*
Employer
Payment Arrangements

None/Self PayCommercialMedicareMedicaid/SoonercareMilitaryOther
To help us better coordinate your care and aleviate errors please provide a selfie and pictures of your ID and insurance cards if you have them.
Take a Selfie!
Front of ID
Insurance Information
Insurance Company
ID/Policy #
Group #
Copay/Co Insurance Amount
Effective Date

MonthDayYear
Date
Front of Insurance Card (If applicable)
Back of Insurance Card (If applicable)
How did you hear about us?

Family/Friend/Word of MouthSocial MediaInternet SearchEmailInsurancePrint/Newspaper/MagazineCommunity EventSchoolReferral from providerOther
Credit Card Information

Diversity Family Health requires a credit card to be placed on file to bill cancellation fee for appointments that are not cancelled within 24 hours.
Name on Card

First NameLast Name
Card Number
Expiration date
Zip Code
Schedule Request

Please complete the information below to be used for your request and once registered the scheduler will contact you..
Location*
Provider
Preferred Day of Week
Preferred Time of Day
Reason for visit
Type of Visit (Choose all that apply)

Primary CareGender Affirming Hormone TherapyHIV PreventionHIV TreatmentTherapy (OK only at this time)Mental Health Evaluation/Medication Managment (OK Only)Other
Once you submit the registration form you will be contacted to confirm your appointment details. We look forward to providing you with great care!
Should be Empty:

Registration Form

Credit Card Information

Schedule Request