Patient Registration

Revised: 09/16/2019

[Image: AccelHealth logo, featuring stylized figures in green, blue, and red forming a heart shape, next to the text “AccelHealth” in black and blue]

Patient Information

Last name

First name

Middle name

Social Security Number

Age

Date of birth

Mailing address

Apt no.

City

State

Zip

County

Home phone

Work phone

Cell phone

Birth Sex

Male

Female

Current Gender

Male

Female

Undifferentiated

Gender Identity

This section is optional for patients under 18.

• Male
• Female
• Transgender male, female-to-male (FTM), trans man
• Transgender female, male-to-female (MTF), trans woman
• Genderqueer, neither male nor female
• Other
• Choose not to answer

Sexual Orientation

Optional for patients under 18.

• Straight or heterosexual
• Lesbian, gay, or homosexual
• Bisexual
• Something else
• Choose not to answer
• Don’t know

Race

May select more than one.

• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or other Pacific Islander
• White
• Choose not to answer

Preferred Pronoun

• He, him, his
• She, her, hers
• Ze, hir
• They, them, theirs
• Other
• Decline to answer

Ethnicity

• Hispanic or Latino
• Not Hispanic or Latino
• Choose not to answer
• Other
• Unknown

Preferred language

Marital status

• Married
• Single
• Divorced or separated
• Widowed

Primary insurance name

Secondary insurance name

Parent Information

Complete this section only if patient is a minor. Not applicable for family planning services.

Parent or Guardian #1

Mailing address

Check if same as above

City, state, zip

Date of birth

Home phone

Work phone

Cell phone

Social Security Number

Employer

Relationship to child

• Mother
• Father
• Grandparent
• Foster parent
• Other

Parent or Guardian #2

Mailing address

Check if same as above

City, state, zip

Date of birth

Home phone

Work phone

Cell phone

Social Security Number

Employer

Relationship to child

• Mother
• Father
• Grandparent
• Foster parent
• Other

Release of Information and Financial Responsibility

I hereby authorize AccelHealth to release any medical or other information needed to process all insurance claims. I authorize payment of insurance benefits directly to AccelHealth. I agree that I am responsible for payments for services rendered, deductibles and coinsurance. I am aware that failure to pay may result in termination of the patient/clinic relationship. A photocopy of this authorization shall be considered as valid as the original. This authorization will remain in effect until revoked by me in writing.

By signing this form, I am saying that I understand what is written above and that I voluntarily ask for and consent to treatment.

Patient or authorized signature

Date

Additional Questions

Please answer the following questions so we may better serve you:

Agriculture and Farm Work

In the last 2 years have you or anyone in your family worked in any type of agriculture, such as planting, picking, preparing the soil, packing house, driving a truck for any type of farm work, or worked with animals? Yes or No

In the last 2 years, have you or a member of your family lived away from home in order to work in any type of agriculture? Yes or No

Have you or a family member stopped migrating to work in agriculture because of a disability? Yes or No

Homeless Status

• Not homeless
• Doubling up
• Shelter
• Street
• Transitional
• Other

Language

• English
• Spanish
• Other: ____________

Emergency Contact

Name

Phone

Veteran Status

Are you a US Veteran? Yes or No

Please give card to staff

Please give card to staff

Communication Preferences

May we leave detailed phone messages? Yes or No

May we mail detailed correspondence to your address? Yes or No

May we text you important reminders? Yes or No

May we email you information? Yes or No

Email address

How Did You Hear About AccelHealth?

• Billboard
• Event sponsor
• Friend or family
• Insurance
• Internet
• Newspaper
• Publication
• Radio
• Social media
• Other