All Care Health Center

New Patient Paperwork

All information requested within this form is essential to ensure quality patient care or required by federal law. It will be kept private and confidential as a part of the patient’s medical record.

First Name *

Last Name *

Middle Initial:

Preferred Name

Your Affirming/Preferred Pronouns:

He, Him, His

She, Her, Hers

They, Them, Theirs

Ze/Hir/Hirs

Decline to answer

Social Security Number (SSN): *

Date of Birth (mm/dd/yyyy): *

Address *

City *

State *

Zip Code *

Preferred Language: *

Interpreter Needed?

How can we reach you?

Please fill out any/all contact methods.

Preferred Phone Number:

If you do not have a phone number please put NA.

The Preferred Phone Number is:

Alternate Phone Number

If you do not have a phone number please put NA.

The Alternate Phone Number is:

Email Address