Intake

							                                                                                                              Print Form

                               ANN SILVERMAN COMMUNITY HEALTH CLINIC

                                                   PLEASE PRINT
TODAY’S DATE: ______/______/__________

PATIENT’S NAME:
BIRTH DATE: Month____________ Day__________ Year ____________                               AGE: ______________
PATIENT’S SOCIAL SECURITY #:
SEX: ______ RACE: _____________ LANGUAGE (that you prefer): English Spanish Other: _______________
HOME PHONE #: __________________________ CELL PHONE OR OTHER #: ___________________________
STREET ADDRESS:                                                                             APT. # ______________
CITY:                                                            STATE: _______________ ZIP: _______________
Mailing or PO Box Address if different than street address:
MAILING or PO BOX ADDRESS:                                                           APT. # ____________
CITY:                                                             STATE: _______________ ZIP: _______________

  If Patient is a Minor:
PARENT/GUARDIAN NAME:
PARENT BIRTH DATE: _______/________/________ PARENT SOCIAL SECURITY #: ___________________
PARENT ADDRESS (if different than above):
CITY: _____________________________________________ STATE: _______________ ZIP: _______________

 Emergency Contact Information:

NAME: __________________________________________ RELATIONSHIP TO YOU: ______________________
ADDRESS: ____________________________________ CITY: ________________ STATE: _____ ZIP: _________
PHONE #: _____________________________________
If we cannot reach you, do we have permission to talk to this person regarding your personal health information?
Yes _____ No ______

Please Answer All of the Following:
            Do you have any health insurance? Yes _____ No _____
            If yes, what is the name of your health insurance company: ___________________________________________

        Are you a Veteran? Yes _____ No ______

        Is this visit in any way related to an accident of any kind or injury on the job? Yes _____ No _____
        If yes, what is the injury?_____________________________________________________________________

            Do we have permission to leave a message on your voicemail or answering machine regarding your
            personal health information? Yes _____ No ______
    •       What pharmacy do you prefer:
            Name: ________________________________ Address: __________________________________

            City/State: ______________________________ Phone: ____________________ Fax: ___________________



Intake09
7/15/2009