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New Patient Registration

Welcome to whole person care. We look forward to serving you.

New patient registration form

Fill out our New Patient Registration form below to make your first appointment a breeze and save time. Please note that this secure form is required in order for us to create your new, HIPAA-protected medical record.

Patient information


Race (select all that apply)

Ethnicity Group

Sexual Orientation (select all that apply)

Are you a US veteran?

How may we contact you?

MyChart 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.

Patient Address

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

Emergency Contact

Which clinic location is your preference? (select one)

Patient assistance

Low vision?

Need an interpreter?

Hard of hearing?

How confident are you filling out this form? (select one)

Disability status

Living status information

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

Where are you presently living?

Financial information

We collect your family size and income information to determine the appropriate contribution amount for your care. You may need to show proof of income to determine your federal poverty level to identify affordable options to your care.

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 “Submit Form” to submit your request.

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