Identity New Patient Registration

Identity New Patient Registration
Today's Date*

MonthDayYear
Date
How did you hear about us
Name*

Patient Legal First NamePatient Legal Last Name
Patient Name Used (if different from Legal Name)
Pronouns*
Patient Date of Birth*

MonthDayYear
Patient Date Of Birth - DO NOT PUT TODAYS DATE
Patient Social Security Number*
Patient Driver's License Number*
Home phone number
Cell phone number*
Work phone number
Patient Email*
example@example.com
Preferred Contact
Patient Mailing Address*
City*
State*
Zip*
Patient Primary Language (Federally Mandated Question - for grant purposes)*
Do you require services provided in another language other than English? Please specify language below: (Federally Mandated Question - for grant purposes)*
Patient Race (Federally Mandated Question - for grant purposes)*
Patient Ethnicity (Federally Mandated Question - for grant purposes)*
Patient Legal Gender*
Patient Assigned Gender at Birth*
Patient Gender Identity*
Patient Sexual Orientation
Patient Marital Status
Employer
Employer Phone Number
Reason for Seeking Care:*
Some options may be: Gender Affirming Care, STI Care, PreP, Primary Care, Medication Management
Emergency Contact Information (Required by Law)

Please tell us who to contact in case of emergency (parent or guardian if under 18); an emergency would be severe bleeding, unconsciousness, accident or a condition requiring ambulance transport or hospitalization. Family planning services DO NOT require parental permission; however, in an emergency situation, if you are under 18 years of age, we will notify a parent or guardian.
Emergency Contact Name*
Emergency Contact Number*
Emergency Contact Relationship to Patient*
Does the person you named above know you are receiving services here?*
For those under 18 or Legal Guardian (only if seeking Gender Affirming Care, Primary Care or Medication Management).

If you are over 18, do not have a legal guardian, or are seeking Family Planning Services without parental consent, please skip to the next section.
Name

Guardian First NameGuardian Last Name
Guardian Name Used (if different from Legal)
Guardian Date of Birth

MonthDayYear
Date
Guardian Mailing Address - Include City, State and Zip
Guardian Email
example@example.com
Preferred Phone
Guardian Social Security Number
Insurance Information
Primary Insurance Name*
Primary Insurance ID Number*
Primary Insurance Group Number
Primary Insurance Start Date

MonthDayYear
Date
Subscribers Name*
Subscribers Date of Birth*

MonthDayYear
Date
Subscribers Relationship to Patient*
VA/TriCare Only: Social Security Number of Member
Identity Health Clinic is able to offer a sliding fee discount for certain services, such as Family Planning Services. Would you like to see if you are eligible for a discount on services? If you select "yes" you must fill out our required form per the requirement of our grant funding. You will also be asked to make your nominal fee payment depending on your income level and this will be discussed at your first appointment. We encourage all patients to apply for the discount program, even if you have insurance.*

YesNo
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Identity Health Clinic and/or insurance companies to release any information required to process my claims.
Patient/Guardian signature*

Clear
Date*

MonthDayYear
Date
My preferred pharmacy is
My preferred Emergency Room is
My preferred imaging facility is
My preferred lab is (Identity Health Clinic utilizes Quest Lab, or we can send your orders elsewhere, we also do some labs in house)
Should be Empty:

Identity New Patient Registration

Emergency Contact Information (Required by Law)

For those under 18 or Legal Guardian (only if seeking Gender Affirming Care, Primary Care or Medication Management).

Insurance Information