Personal Information PLEASE PRINT Sample Clauses

Personal Information PLEASE PRINT. Name: Date: Social Security Number: - - Phone number: Address: City: State: Zip: County: Date of Birth: Age: Sex: Male _ Female Race: White Black Hispanic Other: Marital Status: Single Married Divorced Separated Widowed Other: How many dependent children live with you? Total number of people in your household? Are you the “Head of the Household” Language: English Spanish Other Need Interpreter (Yes or No): E-mail address: Do you work? Where? Monthly income: Living Situation? Rent place Own my home Recovery Facility With a friend With a relative Homeless (if homeless, complete homeless form)** Emergency Contact: Relationship to you: Emergency Contact Phone Number: Do you have ANY health insurance? (PeachCare/Medicaid/Medicare/Blue Cross/Tri-Care/Veteran’s benefits, etc.) Yes No Have you applied for Medicaid? Yes No Have you applied for disability? Yes No Are you a Veteran? Yes Who referred you to the clinic? No Are you eligible for VA benefits? Yes No Athens Area Homeless Shelter Project Safe Friend/Family Mental Health Salvation Army Recovery Program (which one?) Check what you need today: TB Test Medication needed Woman’s exam (pap/breast) STD Test Other Hygiene Item Illness/medical treatment Athens Nurses’ Clinic, Inc. Informed Consent This sheet is to inform you as a new or returning patient about our services, records, fees, and limitations that may affect you as a consumer of our services. If you do NOT understand a statement, please ask and it will be explained to you.

Personal Information PLEASE PRINT. Student’s Last Name Student’s First Name MI Date of Birth: Phone number(s) where student can be reached: Address: City: State: Zip: Do you know of any reason why you should be restricted in physical activity or do you have any other medical condition that you would like first responders to be aware of? Are you taking any medications that first responders may need to know about? Do you have any allergies to food, bees, plants, animals, medications, or other substances? Please note that if you have medical conditions that require preventative or emergency medications (Ex: inhalers, epiPENs, insulin, other), it is your responsibility to bring these required medications with you to all class activities. Emergency Contact Information Name: Relationship: Address: City: State: Zip: Home Phone:

Personal Information PLEASE PRINT. Director Name: (the “Director”) Social Security No.: