PLACE LABEL HERE

PATIENT REGISTRATION FORM (PLEASE PRINT)Patient First Name

Sexual OrientationFor Patients Under 18: Name of Parent/Legal Guardian

MiddleLast Name

/ /

- -

( ) -

INTERPRETER NEEDED YES N\ANO

VETERAN STATUS (Military)

Gender:

Home Address:

Mailing Address: Date of Birth

Home Phone:

Preferred Contact:

NUMBER IN HOUSEHOLD MONTHLY INCOME

Cell: ID/DL#

Email: Social Security Number

Emergency Contact Name:

If you checked "No Permanent Housing,"where are you currently staying?

FHCSD New Patient Registration April 2017 Page 1 of 1

Relationship: Emergency Phone:

State Zip CodeCity

Choose not to disclose M FMF OtherFM

Gender Assigned at Birth: M F

Same as Home

(check one)

HOUSING STATUS EMPLOYMENT I LEARN BEST BY

FARMWORKER OCCUPATION

EDUCATION maximum level

Home E-mailCell NoneText

Don't know/something elseLesbian StraightGay Bisexual

Choose not to disclose

ETHNICITY:

Non-HispanicHispanic

Unknown

Some CollegeGrade

Post GraduateGrade 12 College

RACE:

American IndianAlaskan Native

AsianBlack/African-American

Are you eligible to receive medical care from the VA?Are you a veteran of the US Armed Forces?

Status Yr. DischargedDD214?

Were you ever denied medical care by the VA?If denied medical care, why?

PRIMARY LANGUAGE:

SpanishEnglish

Sign LanguageOther

Middle EasternHawaiian Native

Own or Rent No Permanent Housing (homeless)

Multi-Race

Part/Full-Time StudentEmployed

UnemployedTouchingSeeing

Previous Current

HearingUnknownRetired

NeitherMigrant Seasonal

StreetsShelter

CanyonTransitionalStaying with Family/Friends

Other

Pacific Islander

DeclinedWhite

Unknown

MARITAL STATUS:

Divorced Married

WidowedSeparatedDomestic Partner

UnknownDeclinedSingle

Head of Household

Homeless for how long?

If you tried to use the VA and were dissatisfied, what was the reason?

Yes NoYes NoYes No

SIGNATURE DATE