Important information about Coronavirus

8610 S Sepulveda Blvd Suite 104, Los Angeles, CA, 90045

info@primewellnesschc.org

(310) 659-7867

Patient Registration

Patient Information

If patient is under 18

Parent/Legal Guardian 1 Information

Name

Date of Birth

Relation to the patient

Biological

Adoptive

Foster

Other

Phone number

Occupation

Employer

Bis. Phone

Social Security Number

Driver's Lic. Number

Parent/Legal Guardian 2 Information

Name

Date of Birth

Relation to the patient

Biological

Adoptive

Foster

Other

Phone number

Occupation

Employer

Bis. Phone

Social Security Number

Driver's Lic. Number

Pharmacy Information

Pharmacy Name

Phone Number

Address

Emergency Contact (other than parent/legal guardian)

Name (required)

Relationship (required)

Phone Numbers (required)

Home

Cell

Insurance Type (required)

Medicare

Medi-Cal

Private Insurance

Uninsured

Policy ID/Group # (if applicable)

Send Statements to (required)

Patient

Other

Name

Relationship

Address

City

State

Zip Code

Phone

Advanced Directive Information Received (for patients 18-year-old and older)

Notice of Privacy Practices received

My Consent for Care

Thank you for seeking care from Prime Wellness Community Health Center (PWCHC). This Consent for Care Agreement authorizes PWCHC to provide you with medical care. This form must be signed before you can be treated. The only exception is in cases of emergency.

By signing this form:

I consent to diagnosis, care, and treatment deemed necessary or recommended by my clinician(s) and other healthcare clinicians.
I understand that my consent applies to other PWCHC locations if I choose another clinician or service within PWCHC.

All information provided in this form is true and correct.

I have read, understand and agree to this consent for care agreement.

Name (required)

Date of Birth (required)

Date (required)

Sign Here (print your name) (required)

If signing for the patient, print your name

Date

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