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 PaymentCashCheckCredit CardATM Using your mouse or finger please sign in this box: Please Upload a copy of your Insurance and a photo of your driver's license: Check here if you accept these terms. You will receive a call from us within the hour.