Established Registration – Hilltop Drive

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    Online Registration -
    Established Patient Hilltop Drive

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

    Reason for your visit


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    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

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    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
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