CLIENT PAYMENT INFORMATION

Full Legal Name

Date of Birth

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Are you the primary?

Yes

Insurance Name

If no, THEIR name and DOB

Insurance Card Number

If you have a copy of the card, please upload here

Upload File

Upload supported file (Max 15MB)

Reason for visit

Who can we thank for the referral?

Any special info you'd like to share?

ATTENTION: AS SOON AS YOU CLICK SEND YOU ARE CONSIDERED A CASH PAY CLIENT UNTIL STEP 2 IS DONE.

CLICK HERE FOR THE PATIENT PORTAL. FILL IN AS MUCH INFORMATION AS POSSIBLE.
MAKE SURE TO UPLOAD A COPY OF YOUR INSURANCE CARD IN THE PORTAL.
NEED HELP?? CHECK YOUR EMAIL AFTER YOU CLICK SEND

THANK YOU for your interest in Sunrise Health Clinics. If you are a new or returning client, WELCOME, we're here to help! CLICK HERE to GO TO THE PATIENT PORTAL

IF YOU NEED ASSISTANCE, EMAIL BACK AND WE'LL HAVE A FRIENDLY STAFF MEMBER RETURN YOUR CALL RIGHT AWAY.