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La Red Health Center
302.855.1233

New Patient Form

Complete your patient information and upload your documents to get started with La Red Health Center. This form helps us prepare for your first appointment and ensures we have all the necessary information to provide you with the best possible care.

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New Patient Registration Form

1

Patient Information

Demographics & Background

2

Contact Information

Phone Numbers

Please provide at least one phone number.

Address Information

3

Emergency Contact & Referring Physician

Emergency Contact

4

Employment Information

5

Insurance Information

Primary Insurance

6

Parent/Legal Guardian Information

7

Medical History

8

Preferred Care & Visit Information

9

Pharmacy Information

10

Authorization & Consent

11

Upload Documents

Please upload your insurance cards and any other relevant documents.

12

Patient Certification & Signature

I certify that the information on this form is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay bills at the time of service unless other arrangements have been made. I authorize my insurance claim to be paid directly to the clinic. I further understand my health insurance carrier or payer of my health benefits may pay less than the actual bill for services, and I am ultimately responsible for any balances. I authorize my provider to release any information necessary for my course of treatment or requested by my insurance carrier. I have been offered and/or received a copy of the HIPAA polices of La Red Health Center.

HIPAA Policy:

Use your mouse, trackpad, or finger to sign above. This signature has the same legal effect as a handwritten signature.