Patient Registration

To reduce waiting time, please click the link below to download the registration form. Next, print the form, then fill out all of the information, and bring the printed form with you on your first visit to the nearest DHC healthcare facility to your location.

Download (printable document)

   Patient Registration form  [English Version]
   Patient Registration form  [Spanish Version]

Delta Health Center | Family Medical Care | Mississippi Delta

Documents Needed

  • Photo Identification

  • Insurance card(s), including Medicaid & Medicare

  • All current medications

  • Immunization records

  • Proof of income & address

  • Copayment or sliding fee costs

  • Hospital admission paperwork for emergency room visits within the last 30 days