LaVidaCare Patient Registration Form - WITHOUT

Patient Registration Form

LaVida Care - SFCHC HIV Prevention Program
Please complete each section of the form below, review our patient disclosures and consent declaration, and electronically sign at the bottom of the page before submitting.
Patient Name*

First NameMiddle NameLast Name

CONTACT INFORMATION
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
How may we contact you?*

MailTextPhoneEmail
Emergency Contact Information
Contact Name

First NameLast Name
Relationship
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.
If minor, mother/guardian's name
If minor, father/guardian's name
Please indicate if it is OK for us to leave a confidential voice mail that may include test results, prescription information, or any other medical information pertaining to your health. This will reduce the need for you to return our call if you do not have any additional questions. This should be a phone number where only you, or anyone that you are comfortable with hearing your medical information.
Health Messages*

Yes, you may leave messages with health information at the number below.No, do NOT leave messages with health information.
Phone Number Approved for Receiving Health Messages*
Please enter a valid phone number.
Initials*

AGREEMENT TO PAY FOR TREATMENT
I, the responsible party, hereby agree to pay all the charges submitted by this office during the course of treatment for the patient. If the patient has insurance coverage with a managed care organization, with which this office has a contractual agreement, I agree to pay all applicable copayments, co‐insurance and deductibles, which arise during the course of treatment for the patient. The responsible party also agrees to pay for treatment rendered to the patient, which is not considered to be a covered service by my insurer and/or a third party insurer or other payor.

I understand that San Fernando Community Health Center provides charges on a sliding fee; based on family size and household annual income, and that services will not be refused due to inability to pay at the time of the visit.
Responsible Party*

First NameLast Name
Date*

MonthDayYear
Date
Name and relationship (if not patient)

ACKNOWLEDGEMENT FOR ADVANCE DIRECTIVES
An Advance Healthcare Directive is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions.
Please select one option:

I do have an Advance Directive / Living Will / Durable Power of Attorney for medical or health care decisionsI do NOT have an Advance Directive / Living Will / Durable Power of Attorney for medical or health care decisionsI would like further information on Advance DirectivesI would NOT like further information on Advance Directives.
If you do have an Advance Directive, please make sure to send a copy to us, in person or by mail (732 Mott St, San Fernando, CA 91340).

By signing below, I acknowledge I have received information about Advance Directives.
Responsible Party*

First NameLast Name
Date*

MonthDayYear
Date
Name and relationship (if not patient)

CONSENT FOR TREATMENT
By signing below, I the undersigned patient (or authorized representative, or parent/guardian), consent to and authorize the performance of any treatments, examinations, medical services, surgical or diagnostic procedures, including lab and radiographic studies, as ordered by this office and it’s healthcare providers.
Date*

MonthDayYear
Date
Patient Signature or Guardian (if minor)*

Clear
Name and relationship (if not patient)
Should be Empty: