Registration Forms

Documents

  • A new demographic form must be filled out at each visit to assure correct and current information on each patient.
  • Minors, age 18 and under must have a parent or guardian in attendance at check in. If parent or guardian is unable to attend, patient must provide a parent/guardian name and phone number. The office specialist at the front desk will call the parent/guardian to get consent to treat. If parent/guardian is unable to be reached, the patient cannot be seen until we receive consent.*

To save time at check in, download or print out the appropriate Demographic Form and complete the form before coming in. A valid photo ID and Insurance Card must be provided at time of check in. If the patient is a minor, a parent/guardian must provide their valid photo ID upon check in.

If you have any questions, please call the clinic and we will be happy to help!

Download Adult Demographic Form

Download Minor Demographic Form

*Minors do have the option to be seen without parent/guardian for STD/Pregnancy testing per Nebraska Law.