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:*

MonthDayYear
Date
Marital Status:
Address, City, State, Zip:
Phone Number*

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

MaleFemale
Current Gender Identity

MaleFemaleGenderqueerTransgender Female to MaleTransgender Male to FemaleI do not wish to disclose
Current Sexual Orientation

Lesbian or GayStraight/HeterosexualBisexualDon't KnowI do not wish to disclose
Primary Language*

EnglishSpanishHmongSomali
Interpreter Needed?*

YesNo
Ethnicity Information - Hispanic/Latino identity. Check one option.

Hispanic/LatinoNot Hispanic/LatinoI do not wish to disclose
Race: How do you best identify?

African AmericanAsianAfricanNative HawaiianWhiteOther Pacific IslanderNative American/Alaska NativeI do not wish to disclose
Guarantor Information (If different from patient)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / 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?

YesNo
Additional Patient Information
Are you homeless?

NoYes
Household Size:
Monthly Household Income:
Agricultural Work Status:

SeasonalMigrantYear RoundNon Agricultural
Country of Origin or Birth Country:
United States Military Veteran?
United States Military Veteran?

YesNo
Do you live in public housing?

YesNo
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 NameLast Name
Date of Birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Father/Guardian Information
Name

First NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

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

PATIENT REGISTRATION FORM

Patient Information

Additional Patient Information

Complete if Patient is Under 18 Years Old

Mother/Guardian Information

Father/Guardian Information