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TB Patient Registration Form
Today's Date
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Day
Year
Date
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Address
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Address (include apartment number if applicable)
Street Address Line 2
City
State
Zip
County
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Home Phone Number
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Please enter a valid phone number. If no home phone, please put your cell phone number.
Cell Phone Number
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Please enter a valid phone number. If no cell phone, please put your home phone number.
Sex
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Female
Male
Race
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American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
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Hispanic/Latino
Not Hispanic/Latino
Other
Do you have allergies?
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Yes
No
Please list your allergies
Please list your allergic reactions
Insurance
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Medicaid
Private
Uninsured
Industrial
Medicare
All services are confidential; however, in the event that we do need to contact you regarding a lab result, may we identify ourselves as the Platte County Health Department and leave a message?
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Yes
No
Platte County Health Department has offered me a copy of their "
Notices of Privacy Practices
"
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