Registration Form
To become a patient with Diversity Family Health please complete the form below
Status
Recieved
Booked
Cancelled
Billing Name
*
Prefix
First Name
Last Name
Prefered Name
First Name
Last Name
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
Race
*
America Indian or Alaska Native
Asian
Black or African
Native Hawaiian or Other Pacific Islander
White
Mixed Race
Other
Employer
Payment Arrangements
None/Self Pay
Commercial
Medicare
Medicaid/Soonercare
Military
Other
Front of ID
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)
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
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 Name
Last 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
*
Please Select
Ardmore
Fayetteville
Hot Springs
Little Rock
Oklahoma City
Norman
Tulsa
UCO
Provider
Please Select
Any Provider
Parker Block, MD
Jason Clemons, APRN
Ralph Cornelius, APRN
Amanda Heldenbrand, LCSW
Kim Hill, APRN
Radona Hood, APRN
Kathy Kirk, APRN
Adrian Myers, LCSW
Deanna Prufert, APRN
Russell Rooms, APRN
Jewelle Young, APRN
Laine Soto, LCSW
Preferred Day of Week
Please Select
Any Day
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time of Day
Please Select
Any Time
Morning
Afternoon
Reason for visit
Type of Visit (Choose all that apply)
Primary Care
Gender Affirming Hormone Therapy
HIV Prevention
HIV Treatment
Therapy (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!
Submit Form
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