New Patient Form

Please fill out this form in preparation for your first visit to one of our SEARHC locations.

Basic Information

SEARHC community location?

Heard About Us?

Reason for Appt - CruiseShip

Dental Request Type

Last Name

First Name

Middle Initial

City and State of Birth

Date of Birth

mm/dd/yyyy

Patient's Social Security Number

Other Names Used by Patient?

Demographic Information

Ethnicity

Race

Preferred Language

Gender

Marital Status

Are you currently homeless?

Do you have internet access?

Are you a Veteran?

Contact Information

Country

PO Box or Street Address

City

State, zip code

Cell Phone

Work Phone

Patient's Employer

Insurance Information

Primary Insurance Company

Effective Date

mm/dd/yyyy

Group #

Policy #

Policy Holder's Name

Policy holder's DOB

mm/dd/yyyy

Dependent(s) Name

Secondary Insur.

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone #

Emergency Contact Relationship

Upload Documents

Please upload a photo of your identification, Insurance Card, and 'Certificate of Indian Blood' if applicable. IF YOU ARE USING THE COVID TESTING OR URGENT CARE SITE IT IS VERY IMPORTANT TO UPLOAD THESE DOCUMENTS. Also please bring these documents to SEARHC for your appointment in person.

Drop your files here

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