Western North Carolina Community Health Services Patient Registration Form Fields marked * are required. Patient Information Last Name * First Name * Middle Initial Preferred Name Previously a patient here? * No Yes Mailing Address Street Address * Apartment City * State * ZIP Code * Email Mobile Phone Home Phone Date of Birth (MM/DD/YYYY) * Demographics Race * Asian American Indian / Alaska Native Black / African American White Native Hawaiian Other Pacific Islander Choose not to disclose Ethnicity * Latino / Hispanic Non‑Latino / Hispanic Not reported Emergency Contact Name Relationship Phone Number Pharmacy Information Pharmacy Name Pharmacy Location Healthcare Power of Attorney Yes No Financial Responsibility I understand that my insurance may not cover all charges and that I am responsible for any balance on my account. Payment is required at the time of service. Consent for Evaluation and Treatment I consent to evaluation and treatment by WNCCHS, including diagnostic testing and coordinated care, and acknowledge HIPAA privacy practices. Patient Agreement I agree to comply with clinic policies, keep appointments, and maintain respectful conduct. Signature Patient or Guardian Name (Signature) * Date * Print this form