Three Rivers Health Center - New Patient Enrollment Form

New Patient Enrollment

Please complete the following form to indicate your interest in becoming a patient at Three Rivers Health Center. A member of our staff will follow up with you to gather more information and complete your enrollment.
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Sex at Birth*
Home Phone*
Cell Phone
E-mail
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Current Primary Care Provider
If none, leave blank.
Current Preferred Pharmacy
If none, leave blank.
Other Current Healthcare Providers
If none, leave blank.
Are you a current or past patient at the CTCLUSI Dental Clinic?

YesNo
Are you a CTCLUSI tribal member?*

YesNo
Do you have health insurance?*

Yes - Private InsuranceYes - Medicare / MedicaidYes - Purchased/Referred Care (PRC)No
Current Insurance Provider
If none, leave blank.
Should be Empty: