UHC Patient Form

Patient's Name*

First NameMiddle NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Social Security Number*
Sex

MaleFemale
Preferred Name
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Mailing Address
Street and Apartment Number
City
Zip
County
Physical Address the same as Mailing Address?*

YesNo
Street Address
Street and Apartment Number
City
State
Zip
County
Telephone (Home/Cell)
Contact Method

CellHomeWork
OK to send secure Message?

YesNo
Work Phone
Contact Method

CellHomeWork
OK to send secure Message?

YesNo
Email
example@example.com
Emergency Contact Name
Relationship
Phone
Do you have Medical or Dental Insurance? Please present your insurance card to the Medical Receptionist.

MedicareMedicare AdvantageMedicaidNo InsuranceOther
Primary Medical Insurance Plan
Policy Number
Insured Name/Policy Owner Name
Insured Date of Birth
Relationship to Patient
Secondary Medical Insurance Plan
Policy Number
Insured Name/Policy Owner Name
Insured Date of Birth
Relationship to Patient
Dental Insurance Plan
Policy Number
Insured Name/Policy Owner Name
Insured Date of Birth
Relationship to Patient
Is the Parent or Guardian the same as the patient?

YesNo
Parent or Guardian's Name*

First NameMiddle NameLast Name
Physical Address
Street and Apartment Number
City
State
Zip
Parent/Guardian Employer Name
Parent/Guardian Work Phone
How did you hear about us?

Family/FriendShelterHealth DepartmentHospitalSocial ServicesMediaWICOther
Race (check all that apply)

WhiteAsianAmerican Indian/Alaska NativeBlack/African AmericanNative HawaiianOther Pacific IslanderDeclined to Answer
Ethnicity

Hispanic/LatinoNon-Hispanic/LatinoDeclined to Answer
Preferred Language

EnglishSpanishChineseArabicVietnameseOther
Are interpreter services needed?

YesNo
Sexual Orientation

Straight/not Lesbian or GayLesbian or GayBisexualUnknownDeclined to Answer
What sex were you assigned at Birth?

FemaleMaleDeclined to Answer
Gender Identity

MaleFemaleTransgender Male toFemaleTransgender Female toMaleDeclined to AnswerOther
Do you live in Public Housing?

YesNo
Are you a Veteran?

YesNo
Homeless Status

Not HomelessStreet (living outdoors, encampment, car, makeshift housing)Doubling Up (person who is living with others; arrangement generally considered temporary and unstable)Shelter (organized shelter)Transitional Housing (transitioning from a homeless environment, do not include jail, institutional treatment programs, military, schools or other institutions)
Migrant Farm Worker – Individual who is required to be absent from a permanent place of residence for the purpose of seeking remunerated employment in agricultural work

YesNo
Seasonal Farm Worker – Individual who are employed in temporary farm work but do NOT move from their permanentresidence to seek work; they may also have other sources of employment

YesNo
Please check the box below indicating your estimated annual household income according to the number of people living in your home. United Health Centers is required to report this information to the Federal government, and it helps us to better understand the needs of the communities we serve. No identifying information shall be disclosed to the federal government. Your anonymity is protected.
Number of people in Household

123456
Please list your Pharmacy Information:
Pharmacy Name:
Pharmacy Address
Pharmacy Telephone Number
Patient or Guardian's Signature (Use your mouse to sign on the line)*

Clear
Should be Empty: