Language
English (US)
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Patient Registration Form
Name
*
First Name
Middle Initial
Last Name
Patient Mother's Maiden Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Cell Phone
Please enter a valid phone number.
Birth Date
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Refuse to Report
Can you provide your email?
*
Yes
No, I don't have email
No, I will not disclose
No, Other
Email Address
*
example@example.com
Enable Web Portal
Yes
No
Primary language spoken
*
Limited English Proficiency
Yes
Emergency Contact (other than patient)
First Name
Last Name
Home Phone
Cell Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State
Zip Code
Relationship to Patient
Race
*
White
Black or African-American
Asian
American Indian or Alaskan
Native Hawaiian
Other Pacific Islander
Refuse to Report
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latin
Refuse to Report
Unknown
Disabilities
Handicapped
Visually Impaired
Hearing Impaired
Cognitively Impaired
Other
Veteran
Public housing
Homeless
Special Reason for Becoming Patient
*
None
Interested in a COVID-19 Test
Interested in a COVID-19 Vaccine
Other
Employment Information
Employment Status
Employed Full Time
Employed Part Time
Not Employed
Self Employed
Retired
On Active Military Duty
Reserved for national assignment
Veteran
Employer's Name
Work Number
Please enter a valid phone number.
Migrant Worker
Migrant Farm Worker
Seasonal Farm Worker
Who is responsible for this account?
Myself
Someone else
Name of person(s) responsible for this account
*
First Name
Last Name
Home Phone
*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship(s) to patient
*
Pharmacy Information
Pharmacy Name and Address
Insurance Information
Do you hold Medical Insurance?
*
Not, I am not insured
Yes, I am insured (please provide a copy of your insurance card to Refuah)
Primary Insurance Name
Primary Insurance Address
Primary Insurance ID#
Secondary Insurance Name
Secondary Insurance Address
Secondary Insurance ID#
Authorization
By signing this form, I attest that all of the information above is accurate and true to the best of my knowledge and belief.
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