Transcription of English - Spanish - Northside
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English - Spanish - Northside
Full Name: _____ Date of Birth _____ (First) (Middle) (Last)Gender (circle) Male Female Marital Status (circle) Single Married Divorced WidowedAddress _____City _____ State _____ Zip _____*Preferred Phone Number home cell _____ *Email _____ Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown/DeclinedRace American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White Other Unknown/DeclinedPreferred Language English Spanish Chinese(Cantonese) Chinese(Mandarin) French German Italian Japanese Portuguese Russian OtherEmployer _____ Employer Phone _____Preferred Communication for Appointment Reminders: Phone Call Automated Text Automated Email Patient Agrees that Practice may also rely on patient s expressed
Reorder #26703 PP0004 ANNUAL ACKNOWLEDGEMENT Piedmont Graphics Rev. 04/02/19 English - Spanish FINANCIAL ACKNOWLEDGEMENT ASSIGNMENT OF BENEFITS: Unless I have specified otherwise, verbally or in writing, in consideration of the services provided at Northside Hospital, I hereby assign and transfer to the Hospital and other medical providers all …
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