New Patient Registration

Use this form to register as a new patient. After your information has been submitted, you will be contacted for an appointment.


BEFORE YOU BEGIN, please read our Becoming a Church Health Patient page. Once you’ve done that, complete this New Patient Information form. After submitting the form, you will be contacted for an appointment.

What to Bring

  • Your photo ID
  • Proof of residency (if not on photo ID)
  • A list of all medications
  • Money for your visit to pay co-pays or co-insurance costs
  • Insurance card
  • Proof of Income (if you do not have insurance)

For more information, please read our New Patient Requirements.