Nix Health Care Foundation Outreach Programs
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   and Seminars
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Senior Gold
Events and
   Registration

Become a Member
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   Education
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Application
Become a Senior Gold Member
Nix Senior Gold is a free senior health awareness program offered to adults from age 55. If you or someone you know would like to become a member of Senior Gold, please contact the Senior Gold office at (210) 579-3157, or fill out an on-line application below.

Fields marked with red are required to submit the form.

Senior Gold Membership Application
*Title:  Mr. Mrs. Miss Dr.
*First Name: 
*Last Name: 
*Address: 
*City: 
*State: 
*Zip:   
*Phone:   
Email: 
*SSN:  (Example: 528-56-9811)
*Birthdate:  (Example: 08/27/40)
*Status:  Married Single
 
*Have you ever been a patient in the Nix Health Care System (Nix Hospital or Nix Physician)?
Yes No

Do you have a physician to care for your routine health care needs?
Yes No



If Yes, please list physician(s)


If No, may we provide you with a complimentary physician referral?
Yes No

If you would like a referral, in which specialty are you interested?
 
Spouse or Other Household Member Applying for Membership
Title:  Mr. Miss Mrs. Dr.
First Name: 
Last Name: 
SSN:  (Example: 528-56-9811)
Birthdate:  (Example: 08/27/40)
 
Have you ever been a patient in the Nix Health Care System (Nix Hospital or Nix Physician)?:
Yes No

Do you have a physician to care for your routine health care needs?:
Yes No



If Yes, please list physician(s)


If No, may we provide you with a complimentary physician referral?:
Yes No

If you would like a referral, in which specialty are you interested?: