Appointment Form (Step 1) - CHI EveryYou Health Forms

Patient Information

Communication Consent

Reason for Visit

Labwork/Appointment

Confirmation

"*" indicates required fields

UniqueID

Hidden

Patient_Consent

Let's Get Started!

EveryYou Health connects patients with high quality care, either virtually or in person, at local Community Health Centers. Based on your location, the health center providing your care and treatment will be Community Health Initiatives (CHI).

* required information

Please select one*

New Patient to CHI Health Center

Existing Patient of CHI Health Center

New Patient Information

We just need a few details to get you started! Please answer the questions below.

* required information

Patient Name*

First Name * Last Name *

Phone*

Date of birth*

Email*

Do you have insurance?*

Yes

No

COMMUNICATION CONSENT*

At EveryYou Health we offer communication by text message for your convenience and we find it important to be able to communicate with our patients this way. Please provide your consent to receive text messages below so we can provide you the best possible care.

Yes, I consent to contact via text message (1-5 times per week) from EveryYou Health and my participating Community Health Center (CHC) provider from phone number 43386 and/or 1-866-376-6954. I understand that SMS text is not secure technology and that the messages I receive may include information related to my care and/or services offered by EveryYou Health and my participating CHC provider.**

No, I do not consent to contact via text message.

**Please note that depending on your mobile phone service plan, message and data rates may apply. You may opt-out at any time by replying STOP to the text messages.

Let's Get Started!

New Patient Information

Existing Patient Information