New Patient Registration Paperwork Online Submission

New Patient Registration Paperwork

We invite you to complete your KMC New Patient Registration Paperwork before you arrive for your scheduled appointment. Please submit the forms through our online submission Webform located below.

Supporting Documents

New Patient Registration Page 1 (444 KB)

New Patient Registration Page 2 (509 KB)

General Consent (187 KB)

HIPAA Consent Form (89 KB)

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Name *

Appointment Date

edit-submitted-appointment-date-month

edit-submitted-appointment-date-day

edit-submitted-appointment-date-year

New Patient Registration Page 1 *

Files must be less than 128 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ods.

New Patient Registration Page 2 *

Files must be less than 128 MB.
Allowed file types: gif jpg jpeg png pdf doc docx ods.

Comments: (Specific details regarding your appointment):

Patient Benefits

Contact Information

K’ima:w Medical Center
535 Airport Rd
PO Box 1288
Hoopa, CA 95546
Main Phone: (530) 625-4261

Patient Benefits Office Phone: (530) 625-4261, Ext. 0325
River Ducks Appointments: (530) 625-4261, Ext. 0221
Acorn Appointments: (530) 625-4261, Ext. 0259

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