Patient Registration

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Patient Registration
We are going to gather some information to start the registration process. There will be some additional documents and information needed once you enter the clinic.

  • THIS REGISTRATION PROCESS TAKES ABOUT 3 MINUTES PER PERSON
  • READ EACH SECTION CAREFULLY BEFORE ANSWERING
  • YOU WILL ENTER YOUR BAND NUMBER IN THIS REGISTRATION
  • YOU CANNOT ENTER A BAND NUMBER TWICE, ONLY ONCE IN A REGISTRATION
  • YOU CANNOT LEAVE THE LINE, IF YOU LEAVE THE LINE YOU LOSE YOUR PLACE
  • ANSWER THE QUESTIONS TRUTHFULLY AND ACCURATLLY SO YOU DON'T LOSE YOUR PLACE IN LINE

Contact Info

We are going to ask you about your contact information. The information you provide will NOT be sold or shared beyond those associated with the Clinic and will NOT be used for any purpose other than to make better clinics and services in the future. This contact info may also be necessary for any prescriptions or for the medical staff to contact you.

Demographics

These questions are collecting data on demographics and will not be shared outside of this clinic and are used to help make better clinics and services in the future. Some of this data is being shared with medical staff at the clinic.
Month
Day
Year
Gender
Ethnicity
Would you like to receive emails related to future clinics?
Would you like to receive mobile text related to future clinics?
Do you have health insurance? This is not reported and your answer does not affect whether you receive service today.
Do you have a primary Doctor?
Do you have a regular Dentist?
How did you hear about this clinic?
Choose as many as apply

Language

Do you speak and understand ENGLISH?

Choice of Service

READ CAREFULLY

These questions are to identify what service you are looking for today. You MUST make a final decision on what service you desire. You will NOT be able to change this after registration. You can choose ONE service type. Remember, once you choose you will not be able to change.

  • Dental may include - dental exam, x-rays, cleanings, fillings, extractions
  • Vision may include - eye exam, free prescription glasses
  • Medical may include - screenings (blood pressure, cholesterol, glucose). Medical Consultations, women's health, cancer screening, lifestyle counselling. Foot care, massage (head & neck)
These services are not guaranteed and may be based on availability and medical clearance.
What is your choice of service? Remember, you can only select ONE service selection and you CANNOT change your mind after this registration is submitted. There is NO guarantee that services will be rendered based on capacity. 
MAKE ONE SELECTION
Additional Services

Dental

Dental includes an exam, extras, cleanings, fillings and extractions. But you may select to have cleaning only
In your Dental selection, would you like Cleaning only?

QUESTIONS ABOUT MENTAL HEALTH

We live in a stressful world and there are many demands on us where these become burdens and effect our wellbeing, our emotions and our mental health. There are programs that can help in coping with these stressful situations that we can share with you.
Overall how would you rate your mental health?

PROGRAMS & OTHER SERVICES

There may be additional services or programs available - please indicate if you would like more information on these programs and that we can contact you by the contact information you provided.
Follow-up Program Interest:

You must hit REGISTER for this registration to be complete. You will NOT be able to change your selections once submitted. STAY IN THE LINE AND DO NOT LEAVE YOUR SPACE IN LINE

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