smhwi.com - PCP pre-registration Form

NOTE : A photo ID must be uploaded with this form in order to process your registration. You may take a photo of your ID and other supporting documents, and upload as instructed below. If you have health insurance , please include photos of the front and back of the insurance card. You can upload these images utilizing this form or send them to PCAdmissions@smhwi.com once these steps are completed and the admissions representative will call you to schedule an appointment. When this form is completed an email will be sent to you with instructions on how to set up your patient portal and how to complete your intake forms. Thank you!

Patient Name:

First NameLast Name

Patient Date of Birth

Date

Sex ( assigned at Birth)

MaleFemale

Patient Address: We can only treat Patients with in Arizona

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Emergency Contact Name

Phone Number

Please enter a valid phone number.

Emergency Contact Relationship:

Please select a Payment Option:

Who referred you or source of referral:

Treatment of services Needed:

Annual Preventive care visitChronic Health ProblemsWomen's HealthOther

Reason(s) for appointment/ additional information:

Upload Front and back of insurance card

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Upload ID / Drivers license

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**( patients using insurance will need to provide insurance cards prior to getting on the
schedule)*