New Client Registration Form New Patient Client Registration Form Please allow 24-48 hours for processing I.Patient Name* First Middle Last Suffix Alias or Preferred NameInternet 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneDate of Birth* MM slash DD slash YYYY Sex* Male Female Uknown Birth Sex* Male Female Unknown Sexual Orientation*Lesbian, gay or homosexualStraight or heterosexualBisexualDo not knowChoose not to discloseOther(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 801-486-4877Marital 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/RacesIf 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 PhoneMother's Name First Last PhoneEmail Household# of members of householdTotal Gross Household Income (per month/year):Household Members (optional)NameDOBRelationship 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:YesNoUnknownIs Service Connected Yes No Claim #:Valid VA Card:YesNoDate VA Card Copy Obtained: MM slash DD slash YYYY Upload Copy of VA Card:Max. file size: 2 MB. Description of VA Disability:HomelessYesNoHomeless Type: City State Zip Emergency Contact InformationPrimary Contact Name First Last Primary Contact RelationshipPrimary Contact PhoneSecondary Contact Name First Last Secondary Contact RelationshipSecondary Contact PhoneInsurance InformationDo 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 NamePolicy or Member NumberName of Insured Person First Last RelationshipInsurance #2 NamePolicy or Member NumberName of Insured Person First Last RelationshipDo you have Dental Insurance?* Yes No SignatureFirst Name*Last Name*Email* Date MM slash DD slash YYYY