New Patient Registration Form

P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 P: 907-474-7043 F: 888-837-2146 | www.uaf.edu/chc
New Patient Registration Form
Name

First NameLast Name
Date of Birth
UA ID#
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to text or leave a voicemail at this phone number?
Are you currently living in UAF On-Campus housing?
Do you have plans to live in On-Campus Housing?
If yes, when is your expected move in? (Ex: Fall 2026 or Spring 2027)
Are you a new student needing to upload information? (Ex: Immunization Records, Outside Clinic Notes?
To submit immunization or outside medical records, please log in to the secure patient portal at https://uafchc.uaf.edu/ using your UA credentials.

Immunization records should be uploaded under "Required Forms and Immunizations," and outside medical records should be uploaded under "Optional Form Uploads."

If you are unable to access the patient portal, please submit your immunization records using this alternative form:https://uaf-shcc.jotform.com/232359471634157
Please call us at 907-474-7043, if you need further assistance.
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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