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Attachment C: Patient Registration <br />Client Information: <br />Last Name I First Name 1 Middle Initial <br />Street Address City State/Zip Code Race/Ethnicity <br />(Mark all that apply) <br />Mailing Address (if different) City State/Zip Code o Native American or Alaskan <br />o Asian o White <br />Phone # 1 May we leave a message? O Y 0 I Phone #2 May we leave a message? 0 Y O N o Black or African American <br />N o Hi s pani c/La tin o 0 <br />Birthdate Sex OM OF Marital Status: 0 Single o Married o Divorced <br />(MonthiDay/Year) Other o Separated o Widowed o Partnered <br />Primary Languag e Do you need an Regular Family Doctor or Clinic <br />inte Ll)reter? <br />If client is a minor or deoendent. please flU in iuformation about narent or lee:al 1!uardian: <br />Last Name First Name Middle Initial Relationship <br />o Mother o Father <br />Address City State/Zip Code o Foster Parent 0 <br />Grandparent <br />Phone # 1 M ay we leave a mes sage? o Y 0 I Phone #2 May we leave a message? O Y ON o Legal Guardian <br />N o Other: <br />Health Insurance Info.·mation (mark all that aODlv): <br />o No insurance o Medicare o Medicaid o Private Insurance o Tricare o Other <br />Does the insurance cover immunizations? 0 Yes oNo o I don't know <br />Is there more than one health insurance company? DYes oNo <br />Is health insurance provided through an employer? 0 Yes oNo <br />PLEASE PRESENT INSURANCE CARDS AT TIME OF APPOINTMENT <br />56