Laserfiche WebLink
Attachment D: Patient Registration <br />Client Information: <br />Last Name I 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 • Native American or Alaskan • Asian • White <br />Phone # I May we leave a message? •Y • I Phone #2 May we leave a message? • Y •N • Black or African American <br />N • Hispanic/Latino • <br />Birthdate Sex OM OF Marital Status: • Single • Married D Divorced <br />(Month/DayN ear) Other • Separated • Widowed •Partnered <br />Primary Language Do you need an Regular Family Doctor or Clinic <br />interpreter? <br />If client is a minor or deoendent. olease fJ.ll in information about ca.mot or Jepal e.uardiru1: <br />Last Name First Name Middle Initial Relationship • Mother • Father <br />Address City State/Zip Code D Foster Parent • <br />Grandparent <br />Phone # I May we leave a message? •Y • I Phone #2 May we leave a message? •Y •N D Legal Guardian <br />N • Other: <br />Health Insurance Information (mark all that aoolv): <br />D No insurance • Medicare • Medicaid • Private Insurance • Tricare • Other <br />Does the insurance cover immunizations? • Yes •No • I don't know <br />Is there more than one health insurance company? •Yes •No <br />Is health insurance provided through an employer? • Yes •No <br />PLEASE PRESENT INSURANCE CARDS AT TIME OF APPOINTMENT <br />55