PATIENT REGISTRATION FORM English

PATIENT REGISTRATION FORM
This information is CONFIDENTIAL. The information collected is used to provide you better patient care.
Patient Information
Patient Name: *
Date of Birth: *

Month Day Year
Date
Marital Status:
Address, City, State, Zip:
Phone Number *

Area Code Phone Number
Email:
example@example.com
Type Social Security or Driver's License Number or Refuse *
Sex assigned at birth: *

Male Female
Current Gender Identity

Male Female Genderqueer Transgender Female to Male Transgender Male to Female I do not wish to disclose
Current Sexual Orientation

Lesbian or Gay Straight/Heterosexual Bisexual Don't Know I do not wish to disclose
Primary Language *

English Spanish Hmong Somali
Interpreter Needed? *

Yes No
Ethnicity Information - Hispanic/Latino identity. Check one option.

Hispanic/Latino Not Hispanic/Latino I do not wish to disclose
Race: How do you best identify?

African American Asian African Native Hawaiian White Other Pacific Islander Native American/Alaska Native I do not wish to disclose
Guarantor Information (If different from patient)
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number:
Relationship to Patient
Emergency Contact Name:
Phone Number:
Is it OK to contact them if we cannot reach you?

Yes No
Additional Patient Information
Are you homeless?

No Yes
Household Size:
Monthly Household Income:
Agricultural Work Status:

Seasonal Migrant Year Round Non Agricultural
Country of Origin or Birth Country:
United States Military Veteran?
United States Military Veteran?

Yes No
Do you live in public housing?

Yes No
Authorized Care Givers: The following people are at least 18 years old and authorized to discuss my or my child's health information or bring my child to NHS for evaluation and treatment, including immunizations.
Name:
Relationship:
Complete if Patient is Under 18 Years Old
Mother/Guardian Information
Name

First Name Last Name
Date of Birth:

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Father/Guardian Information
Name

First Name Last Name
Date of Birth
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Take Photo of health insurance card (Front)
Take Photo of health insurance card (Back)
Health Insurance Provider:
Insured ID:
Should be Empty:

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PATIENT REGISTRATION FORM

Patient Information

Additional Patient Information

Complete if Patient is Under 18 Years Old

Mother/Guardian Information

Father/Guardian Information