JHCHC Online Registration

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 Country

Home Phone Number *

Area Code Phone Number

Cell Phone Number *

Area Code Phone Number

Work Number

Area Code Phone Number

Email

example@example.com

Are you Employed? *

Are you a Student? *

Are you a Veteran? *

Date of Birth *

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 Private Insurance Dental Uninsured

Name of Insurance and Policy Number

Upload a copy of your Insurance Card Here:

Browse Files

Name and Address of Pharmacy

Upload a copy of your Insurance Card Here:

Browse Files

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

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