Saban Community Clinic

Welcome to Saban Community Clinic

We are happy you have chosen us for your care.
To register, please complete this form. Several items below will help us ensure that we are meeting your needs.

    PATIENT DEMOGRAPHICS






    Hint
    If you don’t have a Social Security Number, type 999-99-999

    Sexual Orientation:

    Gender:

    Are you a U.S Veteran:

    Disabled:

    SCC will send you mail to the below address. Would you like to communicate with us electronically? If yes, please provide email address so that we can establish an account for you.







    *
    Hint
    Please share an active email to receive clinic updates

    GENERAL INFORMATION

    Marital status:

    How may we contact you:

    My–Chart is a secure online portal where you can view and manage your medical information whenever it's most convenient for you. Features include: Schedule appointments online with your doctor and urgent care.

    Do you live or Go to School in WEHO?
    School:
    School Name:
    Work in WEHO?

    Race:

    Religion:

    Ethnicity Group:

    EMERGENCY CONTACT
    Contact Name:







    EMPLOYMENT INFORMATION

    Employment Status:

    PATIENT ASSISTANCE

    Need an interpreter:

    Written Language :

    How well do you understand this form?

    Visually Impaired:

    Hearing Impaired:

    Special Needs (Select all that applies):

    LIVING PLACE INFORMATION
    Gathering of the following information is to better service your housing needs.

    What Clinic location do you preferred?

    Hint
    choose one location


    Presently where are you living?

    FINANCIAL INFORMATION
    This information is used to determine Federal Poverty Level and to identify a payment bracket. You may need to show a proof of income.

    Hint
    Immediate family only

    Acknowledgment of Responsibility for payments for Services and assignment of Benefits

    I understand that I am responsible for all charges and fees for my care, except any that might be covered by insurance accepted at SCC.
    I understand that payments, including co-insurance, co pays and self-pay/ Sliding Fee payments, is due at the time of Registration. The information on this form is true to the best of my knowledge.

    Please use your mouse or touchpad to sign your name in the grey section below, then click “Send” to submit your request.