UTAH Patient ID and Insurance Card
After submitting your Photo ID and Insurance (if applicable), you will be directed to our full registration form.
Please select the clinic location:
Please Select
Layton
West Valley City
Holladay
Riverton
Sandy
Draper
South Jordan
American Fork
Name
*
First Name
Last Name
Take a picture of your Driver License OR a State ID
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOT IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
What type of payment will you be providing today?
*
Please Select
Cash / Credit Card
Membership ($10 Visit)
Insurance (Not with SelectHealth/IHC)
** We don't take IHC plans nor Select Health
Take a picture the FRONT of your Insurance Card
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOTO IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
Take a picture the BACK of your Insurance Card
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOTO IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
Back
Next
Next Step....... Fill out Section 1 & 2, then SKIP to Section 6 to sign and finish.
You will now be connected to our EMR portal. Fill out section 1 and 2 and then SKIP to section 6 to finish
After you are done, please call the clinic to let us know you have registered online.
Submit and go to registration
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