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  • New patient registration form

    Welcome to Anchor Health! Thank you for choosing us for your care.

  • Use this form to register as a new Anchor Health patient. If you prefer to fill out a paper form, please call 203-903-8308 to request one. Please note that there will be a delay in processing paper forms.

    Please read and follow all instructions. Incorrect or missing information can cause errors in your medical record, delay processing your form, and increase the time it takes to schedule an appointment. All fields marked with an asterisk (*) are required and must be completed to submit your request.

    Registration takes approximately 15 minutes to complete. To quicken this process, please have the following materials ready:

    • Government-issued photo ID (e.g., driver’s license, state-issued identity card, passport, etc.)
    • Emergency contact information
    • Insurance information and card(s), including name and birth date of the insurance subscriber

    For patients under 18 years old, a parent/medical guardian is required to complete this document.

  • Anchor Health respects your right to privacy and confidentiality. All information you submit through this form is protected by the highest security and encryption standards.

    The information we collect helps ensure we provide the best care possible to you and all other community members who use our services.

    We’ll go through 9 sections:

    1. Patient information
    2. Sex, gender, & sexual orientation
    3. Race, ethnicity, & language preferences
    4. Disability & employment status
    5. Housing & contact information
    6. Insurance information
    7. Medical information
    8. Document review & signatures
    9. Wrap-up 

    Submitting this form is a request only. It does not guarantee an appointment, create a medical obligation, or establish a patient-provider relationship with Anchor Health. We may contact you to verify details or decline your request. You are not a patient until you complete your intake appointment with an Anchor Health provider. Until that time, your current, non-Anchor Health provider remains responsible for your care needs, including refills.

  • Let's get started (1/9)

    Tell us more about the services you're seeking from Anchor Health.
  • How can we help you? Please select all that apply.*
  • Are you interested in receiving case management and/or psychiatry services?

  • Patient information (1/9)

    First, provide us with some basic information. These details will help us begin our conversation about you and your care needs.
  • Are you the patient?*
  • Is the patient under 18?*

  • A parent or medical guardian is required to complete this form. We apologize for the inconvenience.

  • Requestor/medical guardian information (1/9)

    First, please tell us about yourself. We'll ask for the patient's information later.
  • What's your relationship with the patient?
  • Format: 000-000-0000.
  • Can we leave voicemails?

  • Who should we contact to schedule this appointment? Please note that if you are not the medical guardian of the patient, we must communicate with the patient as required by federal and state privacy laws.

  • Patient information (1/9)

    Our approach at Anchor Health is to create a health care experience where all patients get groundbreaking, radically inclusive, sex-positive, and gender-affirming care. Unfortunately, many insurance companies and legal entities require us to record your legal name and sex for insurance and billing documents. When addressing you, we’ll always use the name and pronouns you ask us to.
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Sex, gender, & sexual orientation (2/9)

    Next, please tell us about your sex, gender, and sexual orientation. Please speak to your health care provider if you have concerns about adding certain information to your medical record.
  • What sex were you assigned at birth, on your original birth certificate?*
  • Some people are assigned male or female at birth but are born with physical differences in sex anatomy, reproductive organs, chromosomes, and/or hormone function that do not fit typical expectations. These differences are known as variations in sex characteristics, differences in sex development, intersex traits, or sometimes by specific medical terms. Were you born with any of these physical differences?
  • What is your current legal sex in your state?*
  • Below is a list of terms that people often use to describe their gender. Please select all that apply to you.*
  • What are your pronouns? Please select all that apply.*
  • How do you describe your sexual orientation or sexual identity? Please select all that apply.*
  • What is your relationship structure? Please select all that apply.

  • Race, ethnicity, & language preferences (3/9)

    Now we’d like to know about your race, ethnicity, and language preferences. This information helps us better meet your health needs and ensures you get the highest quality care possible.
  • Which of the following best describes you? Please select all that apply.*
  • How well do you speak English?*
  • What language are you most comfortable speaking?*
  • What language are you most comfortable reading?*
  • Do you need an interpreter?*

  • Disability & employment status (4/9)

    Our goal at Anchor Health is to create a space where all patients can fully participate in their care. Please tell us how we can best accommodate you.
  • Do you consider yourself to be a person with a disability?*
  • Are you d/Deaf or do you have serious difficulty hearing?*
  • Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
  • Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?*
  • Do you have serious difficulty walking or climbing stairs?*
  • Do you have difficulty dressing or bathing?*
  • Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?*
  • What is your employment status? Please select all that apply.*
  • Veteran status *
  • Worker status*

  • Housing & contact information (5/9)

    Next, please let us know your housing situation and how we can best contact you. Please note that patient privacy is of the utmost importance at Anchor Health. We know how essential privacy can be for LGBTQ people to receive safe and adequate health care. We use Epic/MyChart as our electronic health record. This system integrates with Yale New Haven Health System (YNHHS). If you have ever been to a facility in the YNHHS network, you may already have contact information in Epic. We will only use the information provided below to contact you.
  • What is your living situation today?*
  • Format: 000-000-0000.
  • Can we leave voicemails?*
  • Format: 000-000-0000.
  • Can we leave voicemails?

  • Format: 000-000-0000.

  • Primary health insurance (6/9)

    If you have health insurance, please find your card as you’ll need it to complete this section. If you don’t have insurance, don’t worry. We offer discounted and/or free services for those who qualify based on family size and income.
  • Do you have health insurance?*
  • We believe everyone deserves access to high-quality, competent, and affirming care, regardless of ability to pay. The Anchor Health Sliding Fee Discount Program removes financial barriers to care by providing discounted and/or free services to eligible persons based on family size and annual income. Are you interested in applying?

  • Got it! We'll email you with your next steps.

  • Please provide your primary insurance information below.

  • Sex with insurance plan/company
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  • What is the patient's relationship to the policyholder?
  • Policyholder date of birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Secondary health insurance (6/9)

    Some people have multiple health insurance plans. Please let us know if you have secondary health insurance.
  • Do you have secondary health insurance?

  • Please provide your secondary insurance information below.

  • Sex with insurance plan/company
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  • What is the patient's relationship to the policyholder?
  • Policyholder date of birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical information (7/9)

    The next few sections collect important information about you and your health. This helps your health care provider prepare for your visit.
  • Which health center do you want to be seen in?*
  • Do you currently have a primary care provider?*
  • Format: 000-000-0000.
  • Are there certain terms that you prefer to use for your body parts? Please select all that apply.

  • Current medications and allergies (7/9)

    Please provide as much detail about your current medications and allergies as possible.
  • Are you currently taking any medications, including long-acting injectables, current implants, over-the-counter medications, vitamins, herbs, supplements, home remedies, or anything else?*
  • Please list all current medications below.
    Rows
  • Do you have any allergic reactions to medicines, foods, or other agents?*
  • Please list all allergic reactions below.
    Rows

  • Medical and surgical history (7/9)

    Please provide as much detail about your medical and surgical history as possible.
  • Have you had any medical problems?*
  • Please list all medical problems below.
    Rows
  • Have you had any surgeries?*
  • Please list all prior surgeries and dates below.
    Rows

  • Please review the following documents (8/9)

  • Patient Rights & Responsibilities

    By checking the box below, I acknowledge that I have received and reviewed a copy of Anchor Health's Patient Rights & Responsibilities (PDF) and agree to abide by such document.

  • Honesty attestation

    Due to increasing attacks on gender-affirming care providers and for the safety of our patients, staff, and community, we require all patients to complete the honesty attestation below before being seen. Thank you for helping us stay safe.

    By checking the box below, I attest that I am at Anchor Health to receive medical services and am not here as a “bad actor” toward this health center or its staff. I agree that I will not take any audio or video recordings of in-person or telehealth appointments, conversations, or any other activities of Anchor Health unless expressly authorized by staff (e.g., as an accommodation for a disability).

  • Appointment Cancellation, No-Show, & Late Policy

    By checking the box below, I acknowledge that I have received a copy of Anchor Health's Appointment Cancellation, No-Show, & Late Policy (PDF) and agree to abide by it.

  • Notice of Privacy Practices

    By checking the box below, I acknowledge that I have received a copy of the Notice of Privacy Practices (PDF) for Anchor Health or that a copy was made available to me and I had an opportunity to review it. I understand that the Notice of Privacy Practices may be revised from time to time, and I may request a copy of the Notice at any visit.

  • Patient Consent Form

    By checking the box below, I consent to receive medical care and treatment from Anchor Health and agree to pay for all charges incurred at the time of service. I acknowledge that I have read all items in the Patient Consent Form (PDF) or had them explained to me and I understand and agree to its contents.

  • Please sign below (8/9)

  • By signing below, I acknowledge that I have received and reviewed the following documents:

    1. Patient Rights & Responsibilities
    2. Honesty attestation
    3. Appointment Cancellation, No-Show, & Late Policy
    4. Notice of Privacy Practices
    5. Patient Consent Form
  • Is the patient signing on their own behalf?
  • Please select the basis for your authority to sign for the patient.

  • Wrap up (9/9)

    Finally, we’d love to know if you have any feedback about this form.
  • How did you hear about us? Please select all that apply.*
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