New Patient Form

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?*

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Heard About Us?

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Reason for Appt - CruiseShip*

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Dental Request Type

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Which Sitka location?*

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Last Name*

First Name*

Middle Initial

City and State of Birth*

Date of Birth*

Father's Name

Required for all patients under 18 years of age.

Father's Date of Birth

Required for all patients under 18 years of age.

Father's Employer

Required for all patients under 18 years of age.

Father's Work Phone

Required for all patients under 18 years of age.

Mother's Name

Required for all patients under 18 years of age.

Mother's Date of Birth

Required for all patients under 18 years of age.

Mother's Employer

Required for all patients under 18 years of age.

Mother's Work Phone

Required for all patients under 18 years of age.

Patient's Social Security Number

Other Names Used by Patient?

Demographic Information

Ethnicity

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Race

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What is your percentage of Native blood?

This information is found on your 'Certificate of Indian Blood' card.

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What tribe do you belong to?

Preferred Language

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Do you require an interpreter?

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Gender*

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Marital Status*

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Are you currently homeless?

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Please define your living situation

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How many people live in your household?

Do you have internet access?

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What kind of internet connection(s) do you have?

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Are you a Veteran?

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Contact Information

Country*

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Other Country

PO Box or Street Address*

City*

State, zip code*

Cell Phone*

Work Phone

Email*

Patient's Employer

Insurance Information

Primary Insurance Company*

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Insurance Name:*

Effective Date

Group #*

Policy #*

Policy Holder's Name*

Policy holder's DOB*

Dependent(s) Name

Secondary Insur.*

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Secondary Insurance Company

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Insurance Name:

Effective Date

Policy #*

Group #*

Policy Holder's Name*

Policy Holder's DOB*

Dependent(s) Name

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.

Drag and drop files here or

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JNU Location

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