Registration Form

  • Patient Information

  • Parent(s)/Legal Guardian(s)/Legal Responsible Party

  • Secondary
  • Income

  • Emergency Contact

  • Insurance Information

    If you are not using health insurance, please complete the Application for Sliding Scale to apply for a sliding scale membership fee based on your income.
  • Medical Information

  • Acknowledgement

    I have provided accurate information to the best of my knowledge and understand that any information I provide will be used by Honey Bee Health Collective for the sole purpose of providing an accurate diagnosis and to provide effective and adequate treatment.