Patient Registration Form - Traditional Healing Program

Patient Registration Form

Traditional Healing Program
Patient Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Parent/Guardian Name (if applicable)*
First and Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Emergency Contact #2*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Medical Provider (Doctor)*
Tribal Affiliation*
Printed Name of Patient (or Parent/Guardian for Minors)*

First NameLast Name
Signature of Patient (or Parent/Guardian for Minors)*

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Date*

MonthDayYear
Date
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