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"
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
If so when did it end*
Please use mm/dd/yyyy format. Try to be as specific as possible
I understand that knowingly providing false information on the above form may make me ineligible for services at NNMFHC. I also understand that it is my responsibility to inform the clinic if any of this information should change.
Patient Electronic Signature*
Date*

MonthDayYear
Date
Should be Empty:

Emergency Contact

Employment Information

Second Job/Spouse/Other Income