Patient Registration Demographic Form

Date: *

Patient Name: *

Last name, First Name, Middle Name

Gender: *

Male

Female

Transgender

Date of Birth: *

Address: *

Address:

City

State/Province

Zip/Postal

Home Phone:

Cell Phone: *

Email Address: *

Emergency Contact Name: *

Emergency Contact Relation to Patient: *

Emergency Contact Cell Phone: *

Do you speak English? *

Yes

No

Do you speak a language other than English at home? *

Yes, I speak:Yes, I speak:

No

Would you like an interpreter if one could be made available? *

Yes, I would like an interpreter that speaks: Yes, I would like an interpreter that speaks:

No

How well do you speak English? *

Very well

Well

Not well

Not at all

What language do you feel most comfortable speaking with your doctor or nurse? *

Race – Check all that Apply: *

Ethnicity – Check all that Apply: *

Not of Hispanic, Latino, or Spanish origin

Cuban

Puerto Rican

Mexican, Mexican American, Chicano

Other Hipanic, Latino or Spanish OriginOther Hipanic, Latino or Spanish Origin

Prefer not to answer

Status: *

Current Housing: *

How did you hear about us? *

I was referred by:

Referred byReferred by

How did you get here today? *

Religion:

Insurance: *

Employment Status (Choose the best description for your situation) *

Have you lived in a shelter, on the streets, or been homeless in the last year? *

Yes

No

Preferred Pharmacy & Location: *

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