Laserfiche WebLink
Attachment D: Patient Registration <br />Client Information: <br />Last Name First Name I 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? LlY LI I Phone #2 May we leave a message? LI Y LIN o Black or African American <br />N o Hispanic/Latino 0 <br />Birthdate Sex OM OF Marital Status: 0 Single o Married o Divorced <br />(Month/DayN ear) Other o Separated o Widowed o Partnered <br />Primary Language Do you need an Regular Family Doctor or Clinic <br />interpreter? <br />If client is a minor or deDel1dent please fill in information aboutparcut or lC2al ~al·djan: <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 May we leave a message? LlY 0 I Phone #2 May we leave a message? OY ON o Legal Guardian <br />N o Other: <br />Health Insurance Information (mark all that apply): <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 />ss