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
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