Adult Registration | Shingle Springs Health & Wellness Center

Patient Information

Patient Name*

First Last

Middle Name

Patient Email*

Preferred Name

Preferred Pronouns

Assigned Sex at Birth*

Gender Identity*

Date of Birth*

Social Security Number*

Refusing to provide a patient and / or policyholder's social security number can cause delays in your insurance company processing claims. If your insurance company is unable to remit payment for services rendered because they cannot confirm your identity, you will be responsible for all charges.

Are you a member of an American Indian or Alaska Native Tribe or descendant of an enrolled member of an American Indian or Alaska Native?*

If Yes, Name of Tribe*

Upload Tribal Documentation*

Max. file size: 10 MB.

If you do not have your tribal documentation, please select "No" and bring documentation to your first appointment. Staff will update once documentation is provided.

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

May We Leave a Message?*

Yes

No

When Did You Move to Current Community?*

Current County*

Marital Status*

Place of Birth*

City State

Can You Access the Internet?*

Secondary Phone Number

Religious Preference

Father's Name

First Last

Mother's Name

First Last

Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Phone Number*

Relationship to Patient*

Patient Information Continued

Are You Employed?*

Employer Name*

Employer Phone Number*

Are You a Veteran?*

Ethnicity*

Race*

If Other Race, Please Specify*

Number in Household*

Total Annual Household Income*

type "0" if you decline to answer

Do You Have an Identification Card or Drivers License?*

ID Upload*

Max. file size: 10 MB.

Next of Kin Information

Next of Kin Name*

First Last

Next of Kin Primary Phone Number*

Relationship to Patient*

Next of Kin Address*

Street Address Address Line 2 City State ZIP Code

Patient Information Continued

Preferred Language*

Do You Need an Interpreter?*

Health Insurance

Do You Have Health Insurance?*

Select All Insurances Services*

Medical

Dental

Vision

Uninsured / Cash Pay

Medical Insurance

Do You Have a Medical Insurance Card to Upload?*

If you do not have an insurance card to upload prior to your appointment, select "No" and please fill out insurance details and bring insurance card(s) to your first appointment. As a reminder, without proper insurance verification, you can be held responsible for any financial charges accrued.

Upload Medical Insurance Card*

Max. file size: 10 MB.

Medical Policy Holder's Name*

First Last

Medical Policy Holder's Legal Sex*

Medical Policy Holder's Date of Birth*

Do You Have Other Medical Insurance?*

Other Medical Insurance

Do You Have Medical Insurance Card to Upload (Other)?*

If you do not have an insurance card to upload prior to your appointment, select "No" and please fill out insurance details and bring insurance card(s) to your first appointment. As a reminder, without proper insurance verification, you can be held responsible for any financial charges accrued.

Upload Medical Insurance Card (Other)*

Max. file size: 10 MB.

Medical Policy Holder's Name (Other)*

First Last

Medical Policy Holder's Legal Sex (Other)*

Medical Policy Holder's Date of Birth (Other)*

Dental Insurance

Do You Have Dental Insurance Card to Upload?*

If you do not have an insurance card to upload prior to your appointment, select "No" and please fill out insurance details and bring insurance card(s) to your first appointment. As a reminder, without proper insurance verification, you can be held responsible for any financial charges accrued.

Upload Dental Insurance Card*

Max. file size: 10 MB.

Dental Policy Holder's Name*

First Last

Dental Policy Holder's Legal Sex*

Dental Policy Holder's Date of Birth*

Do You Have Other Dental Insurance?*

Other Dental Insurance

Do You Have Dental Insurance Card to Upload? (Other)*

If you do not have an insurance card to upload prior to your appointment, select "No" and please fill out insurance details and bring insurance card(s) to your first appointment. As a reminder, without proper insurance verification, you can be held responsible for any financial charges accrued.

Upload Dental Insurance Card (Other)*

Max. file size: 10 MB.

Dental Policy Holder's Name (Other)*

First Last

Dental Policy Holder's Legal Sex (Other)*

Dental Policy Holder's Date of Birth (Other)*

Advanced Directive

Do You Have an Advanced Directive?*

Would You Like Information on an Advanced Directive?*

Have You Provided the Shingle Springs Health & Wellness Center with a Copy?*

Is it Up to Date with Your Current Wishes?*

Household Questionnaire

Are You a Migrant Agricultural Worker?

Are You Currently Homeless / Unhoused?

Patient Signatures

Release of Information Signature*

Release of information, the Shingle Springs Health & Wellness Center has permission to release information needed for insurance processing to my insurance.

Today's Date*

Release of Information

Adult

Registration

To complete this form, you will need the following information and / or documentation:

Adult Registration Form

Patient Information

Emergency Contact

Patient Information Continued

Next of Kin Information

Patient Information Continued

Health Insurance

Medical Insurance

Other Medical Insurance

Dental Insurance

Other Dental Insurance

Advanced Directive

Household Questionnaire

Patient Signatures

Contact Us

Careers

Patient Information

Behavioral Health

Children’s Behavioral Health

Dental

Medical

Pediatrics

Pharmacy

PRC & Specialty Care

Adult

Registration

To complete this form, you will need the following information and / or documentation:

Adult Registration Form

Patient Information

Emergency Contact

Patient Information Continued

Next of Kin Information

Patient Information Continued

Health Insurance

Medical Insurance

Other Medical Insurance

Dental Insurance

Other Dental Insurance

Advanced Directive

Household Questionnaire

Patient Signatures

Behavioral Health

Suicide & Crisis Lifeline

Crisis Hotline Center: 9-8-8

Children's Behavioral Health

Dental Services

Orthodontic Services

Medical

PEDIATRICS

Pharmacy Services

Drug Take Back Program

SPECIALTY CARE SERVICES

ACUPUNCTURE

CHIROPRACTIC

PHYSICAL THERAPY

PODIATRY