Patient registration portal
Basic demographics and contact details. All fields marked * are required.
In my absence or for the benefit of gaining medical advice on my behalf, I authorize the following person(s) to gain patient health information for / with me.
Please include only the members of your household, including your spouse (if applicable) and your children under 18 years of age.
List household members living with you.
Your preferred pharmacy for prescriptions.
Enter ZIP to auto-fill city and state in the address.
Auto-fills from ZIP; you can edit street details.
Do you have any allergies, or have you ever had an adverse reaction to any medication? *
Do you take any medicines? *
Current medications
List medicines you are currently taking.
Confirm the information above is accurate.
General consent. I hereby state that to the best of my knowledge, the above information is current, correct, and true. I understand that it is my responsibility to inform United Community Foundation (UCF) staff if I have changes in any of the information provided here.
UCF uses an appointment reminder system to send reminders and confirmations by email, text, and phone before appointments. I authorize UCF to share limited protected health information with this system and consent to receive these messages via email, phone, and/or text.
Sign with your mouse or finger
