Patient Registration Form

AEHCHC Patient Registration Form

Patient Information

Patient Name
Patient Name
First
Last (include suffix)
Patient Address
Patient Address
City
State/Province
Zip/Postal
Do you need an interpreter?
Are you employed?
Are you a veteran?
Are you a student?
Advanced Directive Information

Health Insurance

What health insurance coverage do you have? Please check ALL that apply.
Maximum upload size: 268.44MB

Parent, Guardian, or Caretaker Information (if applicable)

Parent/Guardian/Caretaker Name
Parent/Guardian/Caretaker Name
First
Last

Emergency Contact Information

Emergency Contact Name
Emergency Contact Name
First
Last

Pharmacy

Address of Pharmacy
Address of Pharmacy
City
State/Province
Zip/Postal

Household Size

Are You the Only Person Living In Your Household?

List the Person(s) Who Live with the Patient

List all the people who live with the patient. To add one person, click the "Add Person" button. To remove one person, click the "Remove Person" button.
Name of Person Living with Patient
Name of Person Living with Patient
First
Last
$.00
Yearly income from a job, SSI, etc.
Maximum upload size: 268.44MB
Add Person Remove Person

Disclosures & Signature

Please read and sign below.

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