Name*

First Last

DOB*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone

Would you like to receive text messages?

Yes
No

Email*

Would you like Portal Access?*

Portal Access: Skypoint Medical Center is pleased to provide you with online access to your health information through our Patient Portal. Here you can view and create new appointments with our practice, exchange secure messages with our staff, update your contact information and insurance, read and print important forms, and access lab results and the latest data on Health . If you want to access an email will be sent to you.

Ethnicity*

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Latino/Hispano
Other

Marital Status*

M
S
W

Languages*

Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Relationship*

Emergency Contact Phone*

How did you hear about the office?

New Patient Registration

Step 1 of 4

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