Your Information

Patient Information

Are you a new patient to Pacific Medical Centers?

No Yes

Appointment is for

Your name

First name

Middle initial (optional)

Last name

Date of birth

Next Next

Insurance Information

Medical insurance

Other insurance or payment type (optional)

Subscriber name

Subscriber date of birth

Subscriber's relation to patient

Subscriber number

Please include any letters in the subscriber ID

Group number

Claims mailing address (optional)

This address can usually be found on the back of your insurance card and will speed the registration process.

Current primary care provider or medical group (optional)

Contact Information

Email address

Confirm email

Best contact/message number

Primary phone type

Alternate contact/message number (optional)

Secondary phone type (optional)

Preferred contact method

May we leave a voicemail?

If your insurance has changed, someone may call you to obtain this information. If you do not receive a call, please present the updated information at check-in.

Step 1 - Your Information

Patient Information

New Patient Details

Insurance Information

Contact Information