Established Registration – Eureka Way Please enter the required information to help us prepare a chart for your visit. 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 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.