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Urban Indian Center of Salt Lake
Info@uicsl.org
120 W 1300 S, SLC UT 84115
(801) 486-4877
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New Patient Client Registration Form
Please allow 24-48 hours for processing
I.
Patient Name
*
First
Middle
Last
Suffix
Alias or Preferred Name
Internet Access
*
Yes
No
Where do you access the Internet?
How did you find out about the Urban Indian Center of Salt Lake?
*
Internet
Family
Friend
Advertisement
Other
What type of UICSL services are you interested in?
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
Date of Birth
*
MM slash DD slash YYYY
Sex
*
Male
Female
Uknown
Birth Sex
*
Male
Female
Unknown
Sexual Orientation
*
Lesbian, gay or homosexual
Straight or heterosexual
Bisexual
Do not know
Choose not to disclose
Other(Define Below)
If other please describe
*
Gender Identity(select all that apply)
*
Male
Female
Female-to-Male (FTM)/Transgender Male/ Trans Man
Male-to-Female (MTF)/Transgender Female/Trans Woman
Genderqueer, neither exclusively male nor female
Choose not to disclose
Other – Additional gender category or other, please specify
Transgender
If other please describe
*
Race
*
Ethnicity
*
Language
*
Who is your Primary Care Provider and location?
What is your preferred Pharmacy?
Pharmacy Address?
Street Address
City
State / Province / Region
ZIP / Postal Code
Date you moved to the Salt Lake Area
*
MM slash DD slash YYYY
Social Security Number
*
Please upload all of the following documentation for Registration: Certificate of Indian Blood or Tribal ID, photo ID, copy of Social Security card, copy of insurance card (if insured - front + back copy) and Proof of Address (lease/bill). Please call Registration office if you have a question on these documents at 801-486-4877
Drop files here or
Select files
Max. file size: 2 MB.
Please call Registration office if you have a question on these documents at 801-486-4877
Marital Status
Single
Married
Partner
Separated
Divorced
Widowed
Unknown
Legally Separated
II.
Indian Total Blood Quantum - Include all tribes the registering client identifies with.
*
4/4
1/2
1/4
1/8
1/16
Enrolled or Descendancy Tribe
*
Tribal Enrollment Number - Found on tribal enrollment document
*
Tribe Quantum of enrolled tribe
4/4
1/2
1/4
1/8
1/16
Other Tribes/Races
If Registering Client is not enrolled with a Tribe, is the Registering Client a Descendant of an Enrolled Tribal Member
*
Yes, a Parent is an Enrolled Tribal Member
Yes, a Grandparent is an Enrolled Tribal Member
No, Client has own Tribal ID or Certificate of Indian Blood
If you're Registering via descendancy, please provide your parent or grandparent's CIB/Tribal ID and Birth Certificate(s) that connects the Registering Client to the parent or the grandparent.
Please Upload the Following: Birth Certificate(s)
Drop files here or
Select files
Max. file size: 2 MB.
If Registering Client is an Enrolled Tribal Member, this does not apply.
Birth Certificate uploaded is of:
Parent
Grandparent
Parent Contact information for Registering Clients ages less than 18 years old:
Father's Name
First
Last
Email
Phone
Mother's Name
First
Last
Phone
Email
Household
# of members of household
Total Gross Household Income (per month/year):
Household Members (optional)
Name
DOB
Relationship
Employed
Yes, part-time
Yes, full-time
Yes, seasonal
No
Retired
Where?
Spouse, Where Are You Employed?
Veteran
Yes
No
Military
Yes
No
Service Branch:
Service Entry Date:
MM slash DD slash YYYY
Service Separation Date:
MM slash DD slash YYYY
Vietnam Service Indicated:
Yes
No
Unknown
Is Service Connected
Yes
No
Claim #:
Valid VA Card:
Yes
No
Date VA Card Copy Obtained:
MM slash DD slash YYYY
Upload Copy of VA Card:
Max. file size: 2 MB.
Description of VA Disability:
Homeless
Yes
No
Homeless Type:
City
State
Zip
Emergency Contact Information
Primary Contact Name
First
Last
Primary Contact Relationship
Primary Contact Phone
Secondary Contact Name
First
Last
Secondary Contact Relationship
Secondary Contact Phone
Insurance Information
Do you have health insurance coverage? This includes any Private Medical Insurance, Medicare, and Medicaid. If yes please upload a copy of your insurance card with your other documents above.
Yes
No
Insurance #1 Name
Policy or Member Number
Name of Insured Person
First
Last
Relationship
Insurance #2 Name
Policy or Member Number
Name of Insured Person
First
Last
Relationship
Do you have Dental Insurance?
*
Yes
No
Signature
First Name
*
Last Name
*
Email
*
Date
MM slash DD slash YYYY
