UAF Legacy Health New Patient Registration - Pride! 2024
Legal Name
*
First Name
Last Name
First Name Used/Preferred Name (if different from legal first name)
First Name Used
Legal Sex
*
Please Select
Male
Female
Legal sex
Date of Birth
*
-
Month
-
Day
Year
DOB
Phone Number
*
Please enter a valid phone number.
Consent to Text (we will text you to register as a patient, if we cannot reach you by phone)
*
Yes
No
Consent to Call (we will call you to register as a patient)
*
Yes
No
Email
*
example@example.com
Consent to Email (we may email you about registering as a patient)
*
Yes
No
How did you hear about UAF Legacy Health?
*
Please Select
Pride - Utah Pride Festival
Pride - Daybreak Pride
Pride - BIG GAY CAR WASH!
Pride - Salt Lake City Pride
Advertising
Primary Care Physician
Specialty Physician
Word of Mouth
Other patients
Hospital
Insurance Company
Test Site - After Hours Community Test Site
Other
Language
*
Please Select
Arabic
Chinese
English
Polish
Portuguese
Russian
Somali
Spanish
Vietnamese
Decline to Answer
Save
Submit
Should be Empty: