New Patient Registration in Fresno

Save time at the front desk

Send us your details before you arrive and skip the clipboard at the front desk. Fields marked with an asterisk are required.

Patient details

First name*

Last name*

Date of birth*

Sex

Phone*

Email*

Street address*

City*

State & ZIP*

Emergency contact & employment

Emergency contact name*

Emergency contact phone*

Relationship

Employer (optional)

Your visit

A short summary helps our team prepare before you arrive.

Reason for your visit*

Preferred pharmacy & location

How did you hear about us?

Signature & consent

Type your full name as your signature*

Date*

I confirm the information above is accurate and I authorize First Health Medical Center to use it to prepare for my visit and to contact me about my care.

Having trouble? Print the PDF version instead, or call (559) 227-2273 and our front desk will take your details by phone.