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Urgent After Hours Care Available

(435) 878-2281

Enterprise Valley Medical Clinic

Healthcare for the Enterprise Valley

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About Our Clinic
- Services
- Providers
- Staff
- Blog
Patient Services
Mental Health
Forms
Contact

New Patient Registration

Patient Information

(Name must be as it is on Birth Certificate / Insurance card.)

Name(Required)

First Middle Last Other / Maiden / AKA Name

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

Sex(Required)

Male

Female

Birth Date(Required)

Month

Day

Year

Employed?(Required)

Yes

No

Retired

Employer

Race/Ethnicity(Required)

Caucasian (White)

Hispanic

Native American

African American

Asian

Mix

Decline to Answer

Other

Marital Status(Required)

Single

Maried

Divorced

Are You a Veteran?(Required)

Yes

No

Allergies(Required)

Preferred Pharmacy(Required)

Emergency Contact

Preferably someone not living in the same house.

Name(Required)

First Last

Relationship(Required)

Phone(Required)

HIPPA(Required)

Yes

No

Other Contact

Name

First Last

Relationship

Phone

HIPPA

Yes

No

Additional HIPPA Authorized Persons

HIPPA Autorization: Persons or organizations who are authorized to make the request for my protected Health Information and/or recieve my health information.

Payment Information

Responsible Party Name(Required)

First Last

Birth Date(Required)

Month

Day

Year

Social Security Number(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Relationship to Patient(Required)

Employer(Required)

Insurance Information

Insurance?(Required)

Medicare

Medicaid

Chip

Private Insurance

None

Other

Insurance Company

Insured's Name(Required)

First Last

Social Security Number(Required)

Birth Date(Required)

Month

Day

Year

Policy/ID Number(Required)

Contact Us:

Email:
staff@evmc.org
Phone:
(435) 878-2281
Fax:
(435) 878-2434
Address:
223 South 200 East,
Enterprise, UT

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