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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

*

A

Male

B

Female

Ethnicity

*

A

Hispanic/Latino/Spanish

B

Non-Hispanic/Latino

C

Chose not to Disclose

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

*

Asian

American Indian

Black/African American

Native Hawaiian

Other Pacific Islander

White

Don't want to Disclose

Sexual Orientation

*

A

Chose not to Disclose

B

Heterosexual

C

Homosexual

D

Bisexual

E

Don't Know

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?

*

A

Yes

B

No

Primary Insurance Information

Additional Insurance Information

Preferred Pharmacy

CCRH Pharmacy will be listed as your preferred pharmacy if no pharmacy information is provided.

Preferred Pharmacy Name

*

Pharmacy Address

*

Pharmacy Phone

*

Employment Information

Employer

Employer Phone

Occupation

Agricultural Worker

*

A

No

B

Yes

Agricultural Worker Type

*

A

Migratory

B

Seasonal

C

Chose Not to Disclose

Migratory – within 24 months of your visit, you have left the community to work elsewhere.
Seasonal – within 24 months of your visit, you are/were paid to work piecework, hourly, daily wages in a season.

Homeless Status

*

A

No

B

Yes

C

Chose not to Disclose

Homeless Status Type

*

A

Homeless Shelter

B

Transitional Housing

C

Doubling Up

D

Street

E

Permanent Supportive Housing

F

Other

Veteran Status

*

A

No

B

Yes

C

Chose not to Disclose

Public Housing

*

A

No

B

Yes

C

Chose not to Disclose

Patient/Parent/Legal Guardian Name

*

Patient/Parent/Legal Guardian Signature

*

Sign here

Date

*