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NEW PATIENT REGISTRATION +
Events
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New Patient Registration Form – Dental

Which NATIVE HEALTH location do you want to establish care?*
First Name*
Middle Initial
Last Name*
What pronoun do you prefer to be addressed by*
- She/Her
- He/Him
- They
- Zie/Hir
- Other
Other*
If minors (under age 18) is the patient, please complete below - Guardians required to provide supporting document
Parent/Guardian Last Name
Parent/Guardian First Name
Relationship to minor
- Mother
- Father
- Guardian
Sex at birth*
- Female
- Male
- Intersex or Undifferentiated
Date of Birth*
MM slash DD slash YYYY
Social Security #*
Preferred NATIVE HEALTH Provider*
Billing Address (street # or PO Box, city, state, zip)*
Street Address City State ZIP Code
Secondary Address (street # or PO Box, city, state, zip)*
Street Address City State ZIP Code

(i.e. temporary/permanent)
Primary Phone Number*
Secondary Phone Number*
Email*
Contact Preference*
- Primary Phone
- Secondary Phone
- Email*
- Text*
May leave voicemail message
- Yes
- No
* NATIVE HEALTH cannot guarantee the security of messages sent by email or text and by initialing here you consent to using email or text even with the risk that the messages may be intercepted and read by a third party. _______ (initial) You have the right to at any time request that NATIVE HEALTH communicate with you using alternative means or to alternative locations. Please ask for assistance if you are interested in changing your contact preferences.
Emergency Contact Name*
Relationship*
Emergency Contact Phone #*
Can we call Emergency Contact for Appointment Reminders?
- Yes
- No
Tribal Information

If you are affiliated with a Native American Tribe, please complete this section. If you are not affiliated with a Native American Tribe skip this section and complete the next section.
Tribe of Membership
Tribe of Quantum
Indian Blood Quantum
Tribal Enrollments #
Other Tribe
Demographic Information

Some of the following questions may be uncomfortable for you to answer, however, your honest answer to the following questions will assist NATIVE HEALTH in providing the best services to you as an individual qualify for resources that support the services we provide.
Ethnicity*
- Not Hispanic Latino
- Mexican/ Mexican American/ Chicano
- Puerto Rican
- Cuban
- Other Hispanic
- Chose not to Disclose Ethnicity
- Decline to Specify Hispanic or Latin Origin
Race*
- Asian Indian
- Chinese
- Filipino
- Japanese
- Korean
- Vietnamese
- Other Asian
- Native Hawaiian
- Guamanian or Chamorro
- Samoan
- Other Pacific Islander
- Black/African American
- American Indian Alaska Native
- White
- Choose not to disclose Race
- Other
Specify:*
Federal Enrolled:*
- Yes
- No
Other
Primary Language*
- English
- Spanish
- Other
Other
Marital Status*
- Married
- Single
- Divorced
- Widowed
- Separated
- Partner
Sexual Orientation*
- Lesbian/Gay/Homosexual
- Bisexual
- Straight/Heterosexual
- Don't want to disclose
- Don't know/ Questioning
- Other
Other
Veteran*
- Yes
- No
What Branch*
Gender Identity*
- Male
- Female
- Transgender Man
- Transgender Female
- Other
- Choose Not to Disclose
Other*
Have you worked as a Migratory Agricultural Worker in the 24 months? If minor, has the minor's parent/ guardian worked as Migratory Agricultural Worker?*
- Yes
- No
Were you employed to work with a specific seasonal agricultural products?*
- Yes
- No
What is your housing status?*
- Doubling Up with Other Friends or Family
- Group home or Sober Living
- Housed by Mental health or Substance Use Treatment Program
- Incarcerated
- Permanent Supportive Housing
- Shelter
- Stably Housed
- Street
- Temporary Supportive Housing/Transitional Housing
Employment
Occupation*
Employer Name*
Employer Address*
Employer Phone Number*
Approximate Total Annual Household Income*
- $0-$20,000
- $21,000-$30,000
- $31,000-$40,000
- $41,000-$50,000
- $51,000-$80,000
- $81,000+
Number of People in your Household*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- Other
(includes spouse and children, under 18 years old)
Other*
Insurance Information
Do you have health insurance?*
- Yes
- No (Skip to next Section)
Primary Plan Carrier Name
Primary Plan Carrier Phone Number
Policy #
Group #
Health Insurance Effective Date
MM slash DD slash YYYY
Policy Holder
- Self
- Other
Name of policyholder
Policyholder Date of Birth
MM slash DD slash YYYY
Do you have other insurance?
- Yes
- No (Skip to next section)
Secondary Plan Carrier Name
Secondary Plan Carrier Phone #
Secondary Policy #
Secondary Group #
Service Discount Program

You may be eligible for a discount on the cost of your health care depending on your family size and gross annual income. Please speak to a Family Health Advocate (FHA) to apply for the Discount Program at NATIVE HEALTH. If you qualify, you can receive a reduced out-of-pocket cost.
Would you like to apply for the Discount Program?*
- Yes (Please see an FHA)
- NO
Would you like to apply for the AHCCCS (AZ State Medicaid)?*
- Yes (Please see an FHA)
- NO
Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge I have received a copy of NATIVE HEALTH/NHW Community Health Center’s Notice of Privacy Practices.
Patient Signature:
Missed Appointments/Late Cancellations

It is very important for you to keep all scheduled appointments. If you are unable to keep an appointment, you must notify us as soon as possible so we can use those appointment times for other patients. Three missed appointments will result in a standby appointment status and may lead to a dismissal from our clinic unless under special circumstances (ie. health crisis, epidemic, global pandemic, etc).
Consent to Film, Photograph and Record

By signing below, I consent to the filming, recording or photographing of me for the purposes of identification, treatment and for NATIVE HEALTH's internal operations, such as quality improvement and educating students and professionals. I understand I will not receive any compensation for any such films, recordings, or photographs.
Consent for Treatment and Agreements of Financial Responsibility

By signing below I am authorizing and consenting to all care and treatment provided by NATIVE HEALTH/NHW Community Health Center and its affiliated health care providers, which may include students, residents, volunteers and other trainees. Through this consent, I am authorizing all care, including medical care, dental care, radiologic and diagnostic examinations, laboratory procedures and tests, and general medical and behavioral health care services requested or ordered by my health care provider. I understand that I may refuse services from a student, resident or trainee.

I authorize NATIVE HEALTH/NHW Community Health Center to submit claims for services rendered to my health insurer(s), including, Medicare, Medicaid, or other insurance company, and assign benefits payable for my services to NATIVE HEALTH/NHW Community Health Center. I understand that unless I am covered by an insurer, including federal and state health care programs, I am responsible for and agree to pay all amounts not paid for by my insurer(s), including applicable coinsurance and/or deductible amounts. If my insurer pays me directly for services rendered by NATIVE HEALTH/NHW Community Health Center, I will provide NATIVE HEALTH/NHW Community Health Center with copies of the insurer’s “Explanation of Benefits” and forward all payments received from my insurer to NATIVE HEALTH/NHW Community Health Center immediately upon receipt.

By signing below, I agree that all of the information that I have provided above is true and accurate to the best of my knowledge, that I have read and understand this form and that all of my questions have been asked and answered. I have been provided a copy of the NATIVE HEALTH “Patient Rights and Responsibilities” and acknowledge I have the responsibility to be involved in my care. I am signing this consent form willingly and voluntarily.
Patient/Legal Representative Signature:*
Date:
MM slash DD slash YYYY
Print First Name:*
Print Last Name:
For MINORS:
Patient Parent/Guardian Signature:*
Date:*
MM slash DD slash YYYY
Patient Parent/Guardian Print Name:*
*For Guardians and Legal Representatives, please provide supporting documents that proves you are the patient’s Guardian/Legal Representative.
Front Desk Representative Name:
Date:*
MM slash DD slash YYYY

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NATIVE HEALTH received the HRSA Patient Centered Medical Home badge. Community Health Quality Recognition badges recognize Health Center Program awardees that have made notable quality improvement achievements.

NATIVE HEALTH Central

4041 North Central Ave., Bldg. C
Phoenix, Arizona 85012
P: (602) 279-5262
F: (602) 279-5390

NHW Community Health Center

2423 West Dunlap Ave. Suite 140
Phoenix, Arizona 85021
P: (602) 279-5262
F: (602) 279-5361

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777 West Southern Ave.
Mesa, AZ 85210
P: (602) 279-5262
F: (480) 264-5222

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