New Patients

Applicant/Parent/Gaurdian Name

First Name Middle Initial Last name

Physical Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Emergency Phone

Email Address

Language

Marital Status

Gender

Date of Birth (mm/dd/yy)

Responsible Party Name (if applicable)

First Name Last Name

Family Size

Responsible Party - Relationship (if applicable)

Household Member #1

Name (First, MI, Last)

Relation

Date of Birth

Gender

Household Member #2

Name (First, MI, Last)

Relation

Date of Birth

Gender

In anyone in the household a U.S. Veteran?

Please list anyone with medical insurance:

What is the name of the insurance?

Please list anyone with dental insurance:

What is the name of the insurance?

Family Size

Household Monthly Income

This information is important in order to determine eligibility for public health insurance such as Medicaid or CHP+.

Which Center are you interested in?

Enrollment Services at International Circle (Main Location) Monday-Friday, 8:00 a.m. - 5:00 p.m. Walk-ins & by appointment.	Family Health Center at Myron Stratton Monday-Friday, 8:00 a.m. - 5:00 p.m. By appointment only.
Family Health Center at Academy Monday-Friday, 8:00 a.m. - 5:00 p.m. Walk-ins & by appointment.	Family Health Center at Union Monday-Friday, 8:00 a.m. - 5:00 p.m. Walk-ins & by appointment.
Family Health Center at Divide Monday-Friday, 8:00 a.m. - 5:00 p.m. By appointment only.	Colorado Springs Senior Health Center Tuesday, Wednesday, Thursday, 8:00 a.m. - 12:00 p.m. By appointment only.
Family Health Center at Fountain Tuesday & Thursday 7:30 a.m. - 4:00 p.m. By appointment only.	Developmental Disabilities Health Center (DDHC) By appointment only.