ONLINE PATIENT REGISTRATION

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1. Who is completing this online registration form?
Note: Relatives, power-of-attorney agents, or lawyers representing veterans submitting this application must provide supporting documents at the time of the patient intake interview.
(e.g., 5-10)
3(a). Current Status of Patient
(please select all that apply)
(please specify if known)
4. Name of Veteran/Patient
(MM/DD/YYYY)
(Please specify your country if other than RMI, FSM, or ROP.)
(Optional. Please skip if not applicable)
(Optional. Please skip if not applicable)
15. Email Address
(Please include your country area code; e.g., Micronesia +691 123456)
17. Contact Method Preferred
(Please select all that apply)
18. SSN or ITIN
(Please select all that apply)
21. Veteran Status
(Select all that apply)
(Please specify if you wish to be scheduled for an eyecare appointment)
(Please specify if you wish to be scheduled for an dental care appointment)
26. Medical History (check all that apply)
(please select all that apply)
27. Deceased Veterans (if applicable)
Note: Only persons completing this application for a deceased veteran should complete this section.
If you have a service-connected disability, you may be able to get an SAH grant if you’re using the grant money to buy, build, or change your permanent home (a home you plan to live in for a long time) and you meet both of these requirements.
Veteran Readiness and Employment (VR&E) helps veterans with service-connected disabilities and employment handicaps prepare for, find and keep suitable jobs. For veterans with service-connected disabilities so severe that they cannot immediately consider work, VR&E offers services to improve their ability to live as independently as possible. This program includes financial aid for education and training at vocational and post-secondary colleges and schools (e.g., online courses and in-person classes). Spouses and dependents of disabled veteran-households are eligible for this program, also.
30. Within the last 2 years have you visited a VA Health facility?
32. Types of Past Surgery (check all that apply)
(Please select all types of surgery that apply)
(Insert a comma between each medication, if more than one)
35. Vaccines received in the last 10 years.
(Select all that apply)
NOTE: This health services program is provided to COFA military veterans without a non-service-connected disability approved under the VA Foreign Medical Program. This health services membership plan covers veterans, and their spouses, and children or dependents within veteran household. Your intake nurse can provide you more details at your first contact appointment.
(e.g., urgent care or immediate surgical needs; prescription refills; name of VHA primary care physician or social worker)
Please specify the name of the "Veteran" completing this medical patient questionnaire. By submitting this form, you agree that you are a U.S. military veteran (or person authorized to act on behalf of a U.S. military veteran) who is applying for health services through SNP Veterans Medical Center & Health Systems Ltd., an authorized provided for Veterans Recovery Network PBC ("VRN") under respective financial aid resources and grant programs offered by the United States Department of Veterans Affairs (the "VA"). Thereby, the Veteran authorizes VRN to review and process this questionnaire to check eligibility or enable the Veteran's access to such health services covered by the VA, in addition to other health benefits offered by VRN. VRN keeps all information submitted by the Veteran hereto confidential and does not share information with third parties that are beyond the authority and scope of the VA, VRN, or affiliated government agencies (e.g., Department of Health).
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