S1 - Patient Information

Name*

First NameLast Name
Middle Initial
Chart #
If you are a dental patient, enter the first three letters of your last name. If unknown, enter "NA"
Social Security Number
If you are not comfortable answering, you may fill out this field upon signing the forms in-person
Date of Birth*

MonthDayYear
Sex*
Your sex assigned at birth. Please enter either "M" or "F" in this field.
Street Address*
Please include City, State, Zip
Mailing Address
If same as Street Address, you can leave blank
County of Residence*
U.S Resident?*

YesNo
Veteran*

YesNo
Martial Status*

MarriedSingleDivorcedWidowedSeparated
Race*

BlackWhiteHispanicAsianOther
Phone # - Cell*
Please enter a valid phone number.
Phone # - Home
If same as Cell, leave blank.
May we text you?*

YesNo
Email address
example@example.com
May we contact you using this email address?

YesNo
Emergency Contact
Emergency Contact: Name*

First NameLast Name
Emergency Contact: Phone #*
Relationship w/ Contact*
What hospital have you been treated at recently?*
If you haven't been to a hospital recently, enter "NA"
Who is your family physician?*
If you don't have one, enter "NA"
How did you hear about the clinic?*
Highest Completed Education Level*

Less than High SchoolHS/Non-graduateHS/GEDHome SchooledSome CollegeAssociate's DegreeCollege GraduateMaster's/Ph.D.
Number of Family Members*
The number is who lives with you and shares your income (children, legal spouses, etc. - NOT roommates). If you live alone, enter 1 into the box.
Employment Information
Employment Status*

Full-timePart-timeSeasonalRetiredStudentUnemployed
Unemployed since
Try to be as specific as possible (mm/dd/yyyy). If employed, leave blank.
Employer
Name of company or business owner. Indicate if self-employed. Skip if unemployed.
Phone Number
Phone # of business or business owner. Skip if unemployed.
Date Hired
Skip if unemployed.
Address of Business
Skip if unemployed.
Second Job/Spouse/Other Income

If this section does not apply to you, please skip
This section applies to...

my second jobmy spouseother income unrelated to my main job
Employment Status

Full-timePart-timeSeasonalRetiredStudentUnemployed
Unemployed since
Try to be as specific as possible (mm/dd/yyyy). If employed, leave blank.
Employer
Name of company or business owner. Indicate if self-employed. If employed, leave blank.
Phone Number
Phone # of business or business owner. If employed, leave blank.
Date Hired
Skip if unemployed.
Address of Business
If employed, leave blank.
Did you previously have health insurance?*

YesNo
What type of insurance do you currently have?*
Should be Empty:

Emergency Contact

Employment Information

Second Job/Spouse/Other Income