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SBHC Enrollment Form

  • Student/Patient Information:

  • Date of Birth:

  • Phone:

  • Alternate Phone Number:

  • E-Mail Address:

  • Social Security Number:

  • Gender:

  • Ethnicity:

  • Race:

  • Language:

  • Sexual Orientation (Circle One - If You Are 18 Years Or Older):

  • Marital Status:

  • Will The Patient Require A Translator:

  • Patient/Legal Guardian:

  • Date of Birth:

  • Relationship:

  • Phone Number:

  • Alternate Phone Number:

  • Emergency Contact:

  • Relationship:

  • Phone Number:

  • Health History:

  • Primary Care Provider:

  • Last Physical Exam:

  • Dentist:

  • Last Dental Exam:

  • Preferred Pharmacy:

  • Select All That Apply:

  • Please explain any medical problems selected above:

  • Additional Health Problems:

  • Current Medications:

  • Health/Dental Insurance (Please give a current copy of card to receptionist):

  • Card Holder/Member Name:

  • Social Security Number:

  • Date of Birth:

  • Phone Number:

  • Relationship to Patient:

  • Responsible Party (If Patient Is Under 18 Years Of Age):

  • Phone Number:

  • Relationship To Patient:

  • Date of Responsible Party's Birth:

  • Social Security Number:

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