The Pink Journey Foundation, Healing California, NCNW and Hands of New Hope Health Service Event
Saturday, August 30, 2025
8:30 am - 5:00 pm
Registration Form
Date Form Filled
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Month
Year
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Date
PATIENT DETAILS:
Name
*
First Name
Last Name
Date of Birth
*
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
dd/mm/yyyy
Age
*
How old are you
Gender
*
Please Select
Born Female
Born Male
Transgendered
Non-binary
Intersex
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Preferred Pronoun
Please Select
She/Her
He/Him
They/Them
Ethnicity
Please Select
African
African American/Black
American Indian or Alaska Native
Asian
Caucasian/White
Latino or Hispanic
Middle Eastern
Native Hawaiian or Pacific Islander
Prefer not to respond
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PATIENT DETAILS - continued:
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Home Phone
Work Phone
Mobile Phone
*
Email
*
yourname@domain.com.au
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EMERGENCY CONTACT
:
Emergency Contact Name
*
First Name
Last Name
Relationship
*
What is your relationship to your emergency contact
Emergency Contact Phone
*
Emergency contact phone number
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SERVICES
:
WHAT SERVICES ARE YOU SEEKING?
*
Dental
Vision
Blood Pressure Check
Glucose/Blood Sugar Check
Flu Shot
Vaccines
Do you want a Mammogram?
*
Yes
No
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How did you find out about our Health Event?
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