Havenscourt - NEW PATIENT REGISTRATION FORM English

Patient Registration Form

La Clínica de la Raza-School Based Health Centers
Name*

Legal First NameLegal Last Name
Middle Name
Preferred Name (Alias)
Date of Birth*

MonthDayYear
Date
Address*

Mailing Address

Street Address Line 2

CityState / Province

Zip
Communication Preference
Indicate if you prefer text, call, or email communication,*

TextCallEmail
Telephone Number*
Please enter a valid phone number.
Is it okay to send text messages to this number?*
Is it okay to send text messages to this number?*
Email
example@example.com
Is it okay to e-mail you on this E-mail?
My-Chart: Is a secure online portal where you can view and manage your medical information. Do you want to sign up? *
Interpreter needed?*

YesNo
Preferred Language*
Visually or hearing impaired
ADDITIONAL PATIENT INFORMATION (please answer all questions)

La Clínica is a non-profit organization committed to serving the needs of our community. This information will help La Clínica
access additional grants to continue helping insured and underserved residents in our communities. This information also helps
us identify clients who may qualify for specialty funded programs or services you may qualify for. This information will become a
part of your confidential medical record.
Marital Status*

MarriedSingleDivorcedWidowedDomestic PartnerLegally SeparatedSignificant Other
Ethnic Group*

Other Hispanic, Latino/a or Spanish OriginCubanMexican, Mexican American or Chicano/aPuerto RicanNon-Hispanic or Latino/aUnknownDeclined to answerOther
Race*

Alaskan NativeAmerican IndianAsian IndianBlack / African AmericanChineseFilipinoJapaneseKoreanNative HawaiianPacific IslanderSamoanWhiteVietnameseGuamanian or ChamorroOther AsianDeclined to answerUnknown
Homeless Status*

Currently not Homeless, I was in the last 12 monthsNot HomelessAt risk for HomelessChild at risk for HomelessHomeless unknown ShelterLiving in ShelterLiving with othersPermanent supportive housingSingle occupancy hotelStreet, camp, bridgeTransitional housingVeteran at risk for homeless
Public Housing*

YesNo
Migrant / Seasonal*

MigrantNeitherSeasonal
Social Determinants of Health
Within the past 12 months, you worried that your food would run out before you got money to buy more?*

Often TrueSometimes TrueNever TrueDecline
Within the past 12 months, the food you bought just didn't last and you didn't have money to buy more?*

Often TrueSometimes TrueNever TrueDecline
Would you like assistance with any of the above items?Type a question*

YesNo
United States Veteran/Military Status*

Active DutyInactive DutyNo Previous ExperienceReservistVeteran
Emergency Contact
Name*

First NameLast Name
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Patient / Legal Guardian (If 17 yrs and under):
Name

First NameLast Name
Middle Initial
Relationship to the Patient
Phone Number Cell
Please enter a valid phone number.
Date of Birth (month, day, year)

MonthDayYear
Date
Address (if different than patient's)

Address (If different)

Street Address Line 2

CityState

ZIP
Employment Status*

ChildFull-timePart-timeNot employedRetiredActive military dutySelf employedStudent-Full timeStudent-part timeDisabled
Patient Employer Name
SOGI Data
Patient's Gender Identity*

FemaleMaleTrans (male to female)Trans (female to male)Non-binary/genderqueerDeclineOther
Patient's Sexual Orientation*

Straight or heterosexualBisexualGayLesbianPansexualDo not knowNon-binary/queerDeclineOther
Sex assigned at birth*

FemaleMaleUnknownNot recorded on birth certificateChoose not to discloseIntersex
Patient's Pronouns*

She/her/hersHe/him/hisThey/them/theirsze/hir/hirsey/em/eirsxe/xem/xyrsve/vir/visPatient's nameUnknownDecline to answerOther
Patient/Guardian Signed*

Clear
Representative Full Name*
Date*

MonthDayYear
Date
Important Document Request: Please provide at least one document for each category listed below.
- For Children: Ages 17 and under: Birth Certificate or Guardianship Power of Attorney.
- Identification: Photo ID or Driver License or any unexpired Identification.
- Proof of Residency Status: Work Permit, Residency Card (Green Card), Citizenship Certificate or American passport.
- Proof of Income: Last Months Pay Stub, Income Tax Declaration, W-2 Form or the Attestation of head of Household Form.
- Proof of address: Utility Bill or rent bill.
- Other: Social Security Card & Insurance Card
Should be Empty:

Patient Registration Form

Communication Preference

Social Determinants of Health

Emergency Contact

SOGI Data