registration – santa fe

You may fill out the online registration form to prepare for your visit to ultiMED or you can download the ultiMED Registration Form and bring it with you.

Your FULL Name (first and last)

Your Telephone Number

Last 4 SSN

Date of Birth

Your Email

Gender
femalemale

Mailing Address:
Address

City

State

Zipcode

Local Address:
Address

City

State

Zipcode

Reason for today's visit

Is this a work related injury?
YesNo
If Yes, Name of Work

Work Phone

HR Contact or Work Supervisor

How did you hear about us?

Primary Insurance Name

Primary Insurance Member Number

Secondary Insurance

Primary Insurance Holder's Name:

Primary's Date of Birth:

Relationship to Patient

By submitting this form electronically, I consent to medical treatment by ultiMED for myself or minor child for whom I am accepting medical and financial responsibility. Upon request, my rights and privileges for privacy and accessibility to my medical records will be explained to me. I realize that my insurance company may not cover all of my expenses and that I may be responsible for any charges that exceed their coverage.
Agree