Today's Date:
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Type of Sickle Cell Disease/SCT:
Please Select
Sickle Cell Anemia (SS)
Sickle Cell Beta + Thal
Sickle Cell Beta 0 Thal
Sickle Cell C (SC)
Sickle Cell Disease (unsure of type)
None
Unknown
Sickle Cell Trait
Gender:
*
Male
Female
Declined to Answer
Race
*
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Declined to answer
Ethnicity
*
Please Select
Hispanic or Latino
Non-Hispanic/Latino
Declined to answer
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Client Intake Signature Validation
I acknowledge that the information I have givenfor the Client Intake is accurate and complete. I consent to services by the Sickle Cell Association of Texas Marc Thomas Foundation.
Today's Date
-
Month
-
Day
Year
Date
Client Name
*
Client Signature (or Parent/Guardian signature If client Is under 18):
*
Submit
Submit
Should be Empty: