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Attachment D: Patient Registration <br />Client Information: <br />Last Name First Name Middle Initial <br />Street Address City State/Zip Code Race/Ethnicity <br />(Mark all that apply) <br />D Native American or Alaskan <br />fl Asian D White <br />D Black or African American <br />D HispaniclLatino D <br />Mailing Address (if different)City State/Zip Code <br />Phone #1 Mayweleaveamessage? o Y D <br />N <br />Phone #2 May we leave a message? o Y o N <br />Birthdate <br />(Month/Day/Year) <br />Sex DM <br />Other <br />DF Marital Status: tr Single D Manied E Divorced <br />D Separated D Widowed DPartnered <br />Primary Language Do you need an <br />intemreter? <br />Regular Family Doctor or Clinic <br />If client is a minor or dependent. please fill in information about parent or lesal suardian: <br />Last Name First Name Middle Initial Relationship <br />I Mother I Father <br />D FosterParent D <br />Grandparent <br />D Legal Guardian <br />D Other: <br />Address City State/Zip Code <br />Phone #1 May*. leaveamessage? o y o <br />N <br />Phone #2 May we leave a message? tr Y O N <br />Health Insurance Information (mark all that appM: <br />D No insurance D Medicare I Medicaid D Private Insurance D Tricare tr Other <br />Does the insurance cover immunizations? E Yes D No E I don't know <br />Is there more than one health insurance company? D Yes D No <br />Is health insurance provided through an employer? D Yes I No <br />PLEASE PRESENT INSURANCE CARDS AT TIME OF'APPOINTMENT <br />55