Established Registration – Eureka Way Please enter the required information and we will prepare a chart for your visit. Online Registration - Established Patients Last Name (required) First Name (required) Middle Initial (required) Birth Date mm/dd/yyyy (required) Complete only if the information has changed Primary Phone Number xxx-xxx-xxxx (required) Cell Phone Number xxx-xxx-xxxx Address (required) City (required) State (required) Zip Code (required) Parent or Legal Guardian Emergency Contact Employer: Primary Insurance Second Insurance Method of Payment CashCheckCredit CardATM Reason for your visit 0 Check here if you accept these terms.