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55 <br /> <br /> <br />Attachment D: Patient Registration <br /> <br /> <br /> <br /> <br /> <br />Client Information: <br />Last Name <br /> <br />First Name <br /> <br /> <br /> <br />Middle Initial <br /> <br /> Street Address City State/Zip Code Race/Ethnicity <br />(Mark all that apply) <br /> Native American or Alaskan <br /> Asian  White <br /> Black or African American <br /> Hispanic/Latino  <br />Other: <br />_________________________ <br />_____________ <br />Mailing Address (if different) City State/Zip Code <br />Phone #1 May we leave a message?  Y  <br />N Phone #2 May we leave a message?  Y  N <br />Birthdate <br />(Month/Day/Year) <br />Sex  M  F <br />Other <br />______________________ <br />_____ <br />Marital Status:  Single  Married  Divorced <br /> Separated  Widowed Partnered <br />Primary Language Do you need an <br />interpreter? <br /> Yes  No <br />Regular Family Doctor or Clinic <br /> <br /> None If client is a minor or dependent, please fill in information about parent or legal guardian : <br />Last Name First Name Middle Initial Relationship <br /> Mother  Father <br /> Foster Parent  <br />Grandparent <br /> Legal Guardian <br /> Other: <br /> <br />________________________ <br />_______________ <br />Address City State/Zip Code <br />Phone #1 May we leave a message?  Y  <br />N Phone #2 May we leave a message?  Y  N <br />Health Insurance Information (mark all that apply): <br /> 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