Transcription of NEW PATIENT REGISTRATION FORM
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NEW PATIENT REGISTRATION FORM
A division of NATIVE HEALTH. NEW PATIENT REGISTRATION FORM. REVISED: 07/2018. PATIENT Name: (last, first, middle initial) Other Names Used/Preferred Name: Sex: Date of Birth: Social Security #: Place of Birth (City, State): Date when you began residing in Phoenix: Marital Status: Single Married Partnered Separated Divorced Widowed Address: (street #, Apt #) City , AZ Zip Code: Home Phone: Cell Phone: Additional Phone: In case of emergency, contact: Relationship: Emergency Phone: Tribe of Membership: Tribe of Quantum: Indian Blood Quantum: Tribal Enrollment Number: Other Tribe: Some of the following questions may be uncomfortable for you to answer; however, your honest responses will assist NATIVE HEALTH in providing the best services for you as an individual. By answering the following questions you will help us to qualify for resources that support the services we provide for you. Ethnicity: Race: Primary Language: (Other) Sexual Orientation: Gender Identity: Sex Assigned At Birth Lesbian/Gay/Homosexual Male Male Straight/Heterosexual Female Female Bisexual Other/Gender Variant/Inter-sex Choose Not To Disclose Something Else/Other Transgender Male/Female-to-Male Don't Know/Questioning Transgender Female/Male-to-Female Choose Not To Disclose Choose Not To Disclose What pronoun do you prefer to be addressed by: She/Her He/Him They Zie/Hir Other: Military Veteran: Yes No If yes, which branch: Migrant Worker: Yes No Homeless: Yes
R 2018 a division of NATIVE HEALTH PATIENT RIGHTS AND RESPONSIBILITIES As the accredited Medical and Dental Home of our patients, NATIVE HEALTH is committed to the following Patient Rights and Responsibilities.
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