Adult Registration Form

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

➞ Patient demographics including social security number and identification card or driver’s license
➞ Tribal identification, if applicable
➞ Medical, Dental, and / or Vision insurance card(s)

Please ensure you have all appropriate documents prior to completing forms. If your screen is left idle for more than one hour, the system may automatically close, and your forms may not be saved.

Important Note

Effective August 2025, the Dental Department is no longer able to accept new patients. This does not apply to Indian Health Service beneficiaries. If you would like to be contacted once we are able to accept new patients, please email [email protected].

Download Adult Registration Form ➞

Adult Registration Form

"*" indicates required fields

Step 1 of 13

SECTION 01 | Patient Demographics

Service(s) of Interest*

Medical

Dental

Behavioral Health

Check all that apply

First Name*

Last Name*

Middle Name

Suffix

Preferred Name

Preferred Pronouns

Biological Sex*

Male

Female

Select One

Date of Birth*

Social Security Number*

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone*

May we leave a message / voicemail?*

Yes

Select One

Are you eligible for Indian Health Services (IHS) benefits (i.e. person of American Indian or Alaska Native descent)?*

If Yes, Name of Tribe*

Upload Tribal Documentation*

Accepted file types: jpg, 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. NOTE: only .jpg files allowed.

What month and year did you move to your current residence?*

Current County*

Marital Status*

Place of Birth*

City State

Can You Access the Internet?*

Religious Preference

Behavioral Health

Your mind matters and so does your story. We provide compassionate, confidential care for individuals of all ages, helping you navigate challenges, strengthen coping skills, and build a more balanced, hopeful life.

We Can Help With

Stress, anxiety, and depression
Trauma, grief, and loss
Relationship or family challenges
Life transitions and personal growth

Services

Therapy: Individual, couples, and family sessions tailored to your needs
Psychiatry: Comprehensive evaluations and medication management to support your treatment goals

No matter where you are in your journey, we’ll meet you with empathy, understanding, and respect.

Take the first step today and call us | (530) 387-4185.

Medication-Assisted Treatment (MAT) ➞

Children's Health Services

Pediatrics

Pediatric care begins at birth and lasts through adulthood so it is important to find a healthcare team who is caring, knowledgeable, and offers support and resources for many years. Our knowledgeable pediatric team provides services to assist patients and their families through their medical journey. We offer fundamental preventative services such as immunizations and well-child care, to healthy developmental services and treatment for chronic illness or injury.

We are excited to announce we are expanding our Pediatric services at our main campus | 5168 Honpie Road | Placerville

Pediatric Registration ➞

Children's Health Services

Behavioral Health

We provide support and resources to patients and their families in a welcoming and stigma free environment. We focus on treating and improving the lives of each patient by assisting them to understand and process their own responses and reactions to manage them in a health and safe way.

We specialize in children and families seeking support with anxiety, depression, grief, trauma, social and behavioral concerns, clinical assessment, medication management, and more.

Located off site | 3106 Ponte Morino Drive, Suite A | Cameron Park

Dental Services

Dental health is an important aspect of your overall health. We offer a complete range of services for the whole family, from routine check-ups to more specialized treatments such as dental implant placement and restorations.

Children as young as 6 months old should begin biannual dental visits.

Orthodontic Services

Our skilled orthodontists utilize a variety of techniques, including braces, retainers, and the revolutionary Invisalign system, to address dental issues and enhance not only oral health but also self-confidence.

Important Note

Effective August 2025, the Dental Department is no longer able to accept new patients. This does not apply to Indian Health Service beneficiaries.

Questions?

Please call the patient benefits coordinator | (530) 387-8037

Medical Services

Your health is a partnership, and we’re honored to be part of your care journey.

We understand that healthcare can feel complex. That’s why we focus on providing continuous, personalized care so you can feel confident and supported every step of the way. Our providers are committed to building lasting relationships based on trust, respect, and open communication.

From preventative care to managing chronic conditions, we’re here to support your needs with seamless access to primary care, specialty services, pediatrics, and pharmacy care.

Pharmacy Services

Our in-house pharmacy fills prescriptions for established Shingle Springs Health & Wellness patients. The Pharmacy is located in our clinic and is open weekdays from 8am-5pm.

Download the "RefillPRO" app for iOS and Android, and enroll in our text messaging service.

Drug Take Back Program

Deposit expired or unused prescription drugs anonymously in the bright green receptacle in our waiting room. No sharps or inhalers.

Specialty Care Services

Our specialists are available when the need arises. To learn about a specific specialty care services modality, or to see if a referral is required, please make an appointment with your healthcare provider.

Acupuncture

Discover the healing art of acupuncture. Our skilled acupuncturist combines Asian massage, acupressure, breath-work, exercises, temperature therapy, magnetic therapy, nutrition, herbal remedies, and dietary supplements to enhance and restore well-being. Experience the holistic approach to health, vitality, and balance.

Chiropractic

Our dedicated chiropractor strives to enhance spinal mobility and overall physical well-being. We offer cutting-edge chiropractic adjustments, techniques, and personalized exercise and rehabilitation programs to help patients unlock their full health potential. Experience the path to improved physical function and vitality with chiropractic services.

Physical Therapy

Our expert physical therapist is committed to guiding patients through crucial rehabilitation, thorough evaluation, and personalized treatment. Our focus is on optimizing functional abilities and enhancing overall quality of life. Discover the path to improved health and well-being through physical therapy.

Podiatry

Our podiatrist is a specialist in diagnosing and treating a wide range of foot, ankle, and lower leg conditions. They are committed to ensuring the health and comfort of your lower extremities, helping you walk, run, and live life to the fullest.

Adult Registration Form

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

Important Note

Adult Registration Form

SECTION 01 | Patient Demographics

SECTION 02 | Emergency Contact

SECTION 03 | Patient Information

SECTION 04 | Next of Kin Information

SECTION 05 | Health Insurance

Medical Insurance

Other Medical Insurance

Dental Insurance

Other Dental Insurance

SECTION 06 | Household Questionnaire

SECTION 07 | Patient Authorization for Treatment

Patient Rights & Responsibilities

Notice of Privacy Practices

Assignment of Benefits

Medications and Allergies

Contact Us

Careers

Patient Information

Behavioral Health

Dental

Medical

Pharmacy

PRC & Specialty Care

Children’s Health Services

Behavioral Health

Pediatrics