UCF Patient Registration

Emergency contacts

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.

Contact 1 *

Name

Relationship

Telephone

Contact 2

Name

Relationship

Telephone

Family details (household information)

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.

Household member 1

First name

Last name

DOB

Relationship

Household income

Income period

Pharmacy

Your preferred pharmacy for prescriptions.

Pharmacy name

ZIP

Enter ZIP to auto-fill city and state in the address.

Phone

Fax

Pharmacy address

Auto-fills from ZIP; you can edit street details.

Allergies & medications

Do you have any allergies, or have you ever had an adverse reaction to any medication? *

Yes No

Do you take any medicines? *

Yes No

Authorization to Consent to Treatment of Minor

Required for patients under 18. Child and pharmacy details auto-fill from the sections above.

Minor patient detected (under 18). Complete this authorization before continuing.

Child information

First name

Last name

Date of birth

Sex

Street address

City

State

ZIP

County

Parent / guardian information

Name of parent / guardian

Relationship

Phone

Pharmacy information

Pharmacy name

ZIP

Phone

Address

Consent

A minor is an individual who is under 18 years of age who is not and has been married or had the disabilities of minority not been removed by the court.

I hereby voluntarily consent and authorize United Community Foundation (UCF) medical and dental staff to provide health care services to the minor child named above. I understand that the health care may include, but is not limited to: examination, diagnosis, laboratory work, x-ray / imaging, anesthetic treatment, administration of medication, other procedures and treatments as deemed necessary, and counseling services (including family planning). I understand that no guarantees have been made to me as to the results of examination or treatment.

This consent remains in effect as long as the minor is a patient of the clinic and I have the authority to give consent.

I am (consent signer name)

I am the

Parent Legal Guardian

Consenting for

Him Her

Signer name, role, and pronoun auto-fill from parent/guardian information and the child’s sex.

Delegated adult caregiver (optional)

Use this only if you authorize another adult (over 18) to accompany the child and consent to treatment.

Print name of adult caregiver

Relationship

Grandparent, Aunt, Uncle, Sister, Brother, Family Friend

Time period permission given

Signature

Print name (parent or legal guardian)

Date

Signature (parent or legal guardian)

Sign with your mouse or finger

Registration acknowledgement

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.

Print name

Date signed

Signature

Sign with your mouse or finger

PATIENT REGISTRATION (MEDICAL)

Patient information

Emergency contacts

Family details (household information)

Pharmacy

Allergies & medications

Authorization to Consent to Treatment of Minor

Child information

Parent / guardian information

Pharmacy information

Consent

Delegated adult caregiver (optional)

Signature

Registration acknowledgement