SCH Outpatient

Patient Information

First name

Valid first name is required.

Last name

Valid last name is required.

Birthdate

Please select a valid month.

Please select a valid day.

Please select a valid year.

Address

Please enter your address.

Address 2 (Optional)

City

Valid city required.

State

Zipcode

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Email Address

Valid email address is required.

Mobile Phone

Valid phone number is required.

Insurance Name

Valid insurance name is required.

Insurance ID

Valid insurance id is required.

Please check this box if you are an established St. Clair Hospital patient.

I consent to receiving email communication from St. Clair Hospital, including, but not limited to, notification of when it is my turn to receive the COVID vaccine, and at the appropriate time, an email invitation with a link to register for the vaccine.

I consent to receiving an email invitation to participate in St. Clair Hospital's Follow My Health patient portal, which I may enroll in, and which will contain an electronic record of the COVID vaccine after I receive it.

I consent to receiving text messages or voicemail messages on my mobile phone.