Online Registration -
Established Patient- Eureka 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

Have you had or done any of the following in the last 14 days?

1. Fever YesNo 

If yes, how high has the fever been?

2. Body Aches YesNo 

3. Cough YesNo 

4. Shortness of breath/Difficulty breathing YesNo 

5. Chills YesNo 

6. Muscle pain YesNo 

7. Diarrhea YesNo 

8. Nausea or Vomiting YesNo 

9. Sore throat YesNo 

10. New loss of taste or smell YesNo 

If yes to any of the above how long have you had the symptoms? Hours Days

11. Recent Travel outside of Redding YesNo 

If yes where? Dates of travel:

12.  Have you had contact with someone traveling into Redding  YesNo 

12. Been around anyone who has been diagnosed positive COVID19 AKA Corona virus or are being considered for testing 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:

Check here if you accept these terms.  You will receive a call from us within the hour.