• 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!

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  • Patient Address: We can only treat Patients with in Arizona

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

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