SBHC Enrollment Form



  • Student/Patient Information:



  • Date of Birth:


  • Phone:

  • Alternate Phone Number:

  • E-Mail Address:

  • Social Security Number:

  • Gender:





  • Ethnicity:



  • Race:








  • Language:






  • Sexual Orientation (Circle One - If You Are 18 Years Or Older):







  • Marital Status:







  • Will The Patient Require A Translator:



  • Patient/Legal Guardian:

  • Date of Birth:

  • Relationship:

  • Phone Number:

  • Alternate Phone Number:

  • Emergency Contact:

  • Relationship:

  • Phone Number:

  • Health History:


  • Primary Care Provider:

  • Last Physical Exam:

  • Dentist:

  • Last Dental Exam:

  • Preferred Pharmacy:

  • Select All That Apply:















  • Please explain any medical problems selected above:

  • Additional Health Problems:

  • Current Medications:

  • Health/Dental Insurance (Please give a current copy of card to receptionist):


  • Card Holder/Member Name:


  • Social Security Number:

  • Date of Birth:

  • Phone Number:

  • Relationship to Patient:

  • Responsible Party (If Patient Is Under 18 Years Of Age):




  • Phone Number:

  • Relationship To Patient:

  • Date of Responsible Party's Birth:

  • Social Security Number:


* = Required