Established Registration – Eureka Way

Please enter the required information to help us prepare a chart for your visit.

Online Registration -
Established Patient- Eurkea Way

If you have not been seen for over a year, please go to New Patient Registration

Reason for your visit


0

Please Use Legal Name

Last Name (required)

First Name (required)

Middle Initial (required)

Birth Date mm/dd/yyyy (required)

 

Covid-19 Screen

Number of days with acute illness:

Exposed to anyone with known positive COVID-19

YesNo

Fever or Body Aches: YesNo

Upper Respiratory Infection:YesNo

Cough:YesNo

Shortness of breath: YesNo

Recent Travel out of Redding: YesNo

Contact with someone traveling into Redding

YesNo

Primary Phone Number xxx-xxx-xxxx (required)

Complete only if the information has changed

Cell Phone Number xxx-xxx-xxxx

Address

City

State

Zip Code

Spouse or Legal Guardian

Emergency Contact

E-maill Address

Employer: If visit is related to employment, please complete this section.

Primary Insurance

Second Insurance

Method of Payment
CashCheckCredit CardATM


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Please Upload a copy of your Insurance and a photo of your driver's license:

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