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CCRH New Patient Packet
New Patient Intake Information
Patient Name
*
Address
*
City
*
State
*
Zip Code
*
Home Phone
*
SSN
*
Date of Birth
*
Mobile Phone
*
Email
*
Gender
*
Gender
A
Male
B
Female
Ethnicity
*
Ethnicity
A
Hispanic/Latino/Spanish
B
Non-Hispanic/Latino
C
Chose not to Disclose
Gender Identity
*
Gender Identity
A
Male
B
Female
C
Transgender M to F
D
Transgender F to M
E
Other
F
Don't want to Disclose
Race
*
Race
Asian
American Indian
Black/African American
Native Hawaiian
Other Pacific Islander
White
Don't want to Disclose
Sexual Orientation
*
Sexual Orientation
A
Heterosexual
B
Homosexual
C
Bisexual
D
Don't Know
E
Chose not to Disclose
Marital Status
*
Marital Status
A
Single
B
Married
C
Widowed
D
Divorced
E
Separated
F
Partner
Preferred Language
*
Emergency Contact
Emergency Contact Name
*
Relationship to Patient
*
Emergency Contact Phone Number
*
Do you have health insurance?
*
Do you have health insurance?
A
Yes
B
No
Preferred Pharmacy
CCRH Pharmacy will be listed as your preferred pharmacy if no pharmacy information is provided.
Preferred Pharmacy Name
*
Pharmacy Address
*
Pharmacy Phone
*
Are you currently employed?
*
Are you currently employed?
A
Yes
B
No
Agricultural Worker
*
Agricultural Worker
A
No
B
Yes
Homeless Status
*
Homeless Status
A
No
B
Yes
C
Chose not to Disclose
Veteran Status
*
Veteran Status
A
No
B
Yes
C
Chose not to Disclose
Public Housing
*
Public Housing
A
No
B
Yes
C
Chose not to Disclose
Patient/Parent/Legal Guardian Name
*
Patient/Parent/Legal Guardian Signature
*
Sign here
Date
*
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