JHCHC Online Registration

PATIENT Registration Form
Reason for the visit *
Patient Name *

First Name Middle Name Last Name Suffix
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Work Number

Area Code Phone Number
Email
example@example.com
Parent or Guardian

First Name Last Name
Parent or Guardian Phone

Area Code Phone Number
Parent or Guardian Date of Birth

Month Day Year
Date
Parent or Guardian Email
example@example.com
Are you Employed? *
Are you a Student? *
Are you a Veteran? *
Date of Birth *

Month Day Year
Date
Social Security Number
Marital Status: *
Gender Identity *

Male Female Transgender Male (Female to Male) Transgender Female (Male to Female) Choose Not To Disclose
Sexual Orientation *

Lesbian Straight (Not Lesbian or Gay) Bisexual Something Else Don't Know Choose Not To Disclose
What is your Race? *
What is your Ethnicity? *
What is your Primary Language? *
Do you need an interpreter? *
Emergency Contact Name *

First Name Last Name
Emergency Contact Number *

Area Code Phone Number
Advance Directive Information *

Yes, I have an Advance Directive No, I but I would like more information No, I am not interested in Advance Directive
What health insurance coverage do you have? Please check ALL that apply. *

Medicaid Medicare Blue Cross Blue Shield Humana United Healthcare WellCare Private Insurance Dental Uninsured
Name of Insurance and Policy Number
Upload a copy of your Insurance Card Here:

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Name and Address of Pharmacy
Upload a copy of your Insurance Card Here:

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PLEASE INDICATE YOUR CURRENT LIVING ARRANGEMENTS: *
Jackson Hinds Sliding Fee Discount Program

LIST ALL PERSONS LIVING IN HOUSEHOLD BELOW *

RELATIONSHIP TO THE PATIENT

AGE

INCOME (Job, SSI, etc.)

PATIENT NAME

NAME

TOTAL YEARLY INCOME

Upload a copy of your Proof of Income Here:

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By electronically signing your signature, you are agreeing that you have read and understood the above and consent to submit your application electronically.
Signature *

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JACKSON-HINDS COMPREHENSIVE HEALTH CENTER CONSENT FORMS
By electronically signing your signature, you are agreeing that you have read and understood the above and consent to submit your application electronically.
PATIENT/PARENT/GUARDIAN SIGNATURE: *

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PATIENT Registration Form