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Attachment D: Patient Registration <br />Client Information: <br />Last Name I First Name ~ 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 <br />• Asian • White <br />Phone # 1 May we leave a message? DY • I Phone#2 May we leave a message? 0 Y ON • Black or African American <br />N • Hispanic/Latino • <br />Birthdate Sex •M •F Marital Status: • Single • Married • Divorced <br />(Month/Day/Year) 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 fill jn information about oarent or Ie11al mtardian: <br />Last Name First Name Middle Initial Relationship <br />• Mother • Father <br />Address City State/Zip Code • Foster Parent • <br />Grandparent <br />Phone # 1 May we leave a message? DY • I Phone #2 May we leave a message? DY ON • Legal Guardian <br />N • Other: <br />Health Insurance Information (mark all that anolv): <br />D No insurance D Medicare D Medicaid D Private Insurance • Tricare • Other <br />Does the insurance cover immunizations? • Yes •No D 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