Guarantor/Responsible Party Information
-skip if patient is 18+ and responsible for self
Additional Patient Data
This information is for demographic reporting purposes only and will not affect your care. We use this information to apply for grants and other financial assistance, and to ensure that we're providing the best care to all of our patients. If you do not wish to answer any of these questioins, please leave them blank. If you have any questions, please speak with an NHC staff member.
By typing below, I acknowledge that I have read and understand the above statements.