Patient Registration: English Order Number Last Name: * First Name: * Middle Name: Social Security Number: Age: * Date of Birth: * Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec. Day * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: * 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Mailing Address: * Apartment Number: City: * State: * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: * County: * Please answer the following questions so we may better serve you: Please select your primary AccelHealth clinic location * DeLeon Brownwood, Hwy. 377 Brownwood, 104 South Park Stephenville In the last 2 years have you or anyone in your family worked in any type of agriculture (farm work) like: planting, picking, preparing the soil, packing house, driving a truck for any type of farm work, worked with animals? YES YES 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 YES NO Have you or a family member stopped migrating to work in agriculture because of a disability? YES YES NO Home Phone: Work Phone: Cell Phone: Emergency Contact Name: Phone: Birth Sex: * Male Female Current Gender: * Male Female Undifferentiated Sexual Orientation (Optional If under 18): Straight or Heterosexual Lesbian, Gay, or Homosexual Bisexual Something Else Choose Not To Answer Don't Know Gender Identity (This Section Optional For Patients Under 18) Male Female Transgender Male/Fmale-To-Male(FTM)/Trans Man Transgender Female/Male-To-Female(MTF)/Trans Woman Genderqueer Neither Male Nor Female Other Choose Not To Answer Preferred Pronoun: He Him His She Her Hers They Them Theirs Ze Hir Other Choose Not To Answer 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 Ethnicity: Hispanic or Latino Not Hispanic or Latino Other Unknown Choose not to answer Preferred Language: English Spanish Other Language Marital Status: Married Single Divorced/Separated Widowed Are You A US Veteran? YES NO Homeless Status: Not Homeless Doubling Up Shelter Street Transitional Other How Did You Hear About AccelHealth? Billboard Newspaper Event Sponsor Publication Friend/Family Radio Insurance Social Media Internet Other Primary Insurance: (Please Give Card To Staff) Secondary Insurance: (Please Give Card To Staff) May we leave detailed phone messages? * YES NO May we mail detailed correspondence to your address? * YES NO May we text you important reminders? * YES NO May we email you information? * YES NO Email Address: COMPLETE THE FOLLOWING SECTIONS ONLY IF PATIENT IS A MINOR (NOT APPLICABLE FOR FAMILY PLANNING SERVICES) Parent / Guardian #1 MAddress1 Mailing Address: (Check If Same As Above) Street/PO box 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 Other Parent / Guardian #2 MAddress2 Mailing Address: (Check If Same As Above) Street/PO box 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 Other RELEASE OF INFORMATION/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 Name: (Please Type) * Date: * THANK YOU FOR CHOOSING ACCELHEALTH!