2019 DCFC Registration Information
Dakota Child and Family Clinic must have complete and accurate information about you/your child in order to provide you with the most appropriate care, including processing your insurance claims. You must provide a driver's license, government ID card or other, official identification at every visit.

You will be asked to review your registration to ensure accuracy of all personal information. Please read and review this information carefully. Report any changes in address, insurance, e-mail and/or telephone number immediately.

You will be asked to sign an Assignments of Benefits for, which allows us to bill your insurance company and receive payments directly from the insurance company. If you do not sign this form we hold the right to consider you to self-pay and may ask you to pay cash at the time of your visit.

Email address *
Patient Name *
First and last name
Your answer
Patient Date of Birth *
MM
/
DD
/
YYYY
Gender Identity *
Mobile Phone
Your answer
Home Phone
Your answer
Contact Preferences
Mobile Phone
Home Phone
Preferred number
Can we leave a detailed voicemail?
Home Address, Apt #, City, State, ZIP *
Your answer
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