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| Alias/Maiden Name Last, First, MI | | |
| * Gender | | |
| Preferred Pronoun May be discussed with provider privately, if preferred | | |
| * Date of Birth | |
| Social Security # | | |
| Reason why SS# not provided | | |
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Physical Address | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | (Home)
| | (Business) | | (Cell)
| | | Message may be left at above phone number? | | | | | Yes No | | Yes No | | Yes No | | Email: | | |
| * County of Legal Residence Please enter the county that you legally reside in. | | |
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Mailing Address Place the address where you receive mail, if different from physical address. | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | | | (Business) | | (Cell)
| | Email: | | |
| * Ok to send mail? | |
| * Ok to send email? | |
| * Is it ok to leave a voicemail? | |
| Preferred means of communication (Appointment Reminders) | |
| Special Calling Instructions | | |
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| Client Legal Status | |
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Legal Guardian Person who has legal responsibility of the client, if yourself, please skip. | | Name: | | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | (Home)
| | (Business) | | (Cell)
| | Relationship: | | | Email: | | |
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Emergency Contact Person to call in the event of a emergency. | | Name: | | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | (Home)
| | (Business) | | (Cell)
| | Relationship: | | | Email: | | |
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Payee Person Person who handles the clients financial situation. | | Name: | | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | (Home)
| | (Business) | | (Cell)
| | Relationship: | | | Email: | | |
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| Marital Status | | |
| Race | | |
| Ethnicity | | |
| Language | | |
| Religion | | |
| Hospital of Choice Please enter the hospital of your choice. | | |
| Are you currently in Hospice or Palliative care? HospicePalliativeCare | | |
| Is this person in special education? | |
| Last Grade Completed | | |
| School | | |
| School District | | |
| Interpreter needed? | |
| Employment Status | | |
| Household Annual Income | | |
| Living Arrangement foster care, group home, etc | | |
| Household Composition single adult, significant other, etc | | |
| Does Client have an Advanced Directive? | |
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Relationship 1 | | Name: | | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | (Home)
| | (Business) | | (Cell)
| | Relationship: | | | Email: | | |
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Relationship 2 | | Name: | | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | (Home)
| | (Business) | | (Cell)
| | Relationship: | | | Email: | | |
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| Referral Facility Name | | |
| Referral Address | | |
| Referring Provider | |
| Did the Client Provide the Information? | |
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Person providing information if not the client | | Name: | | | Address: | | | Address Line 2: | | | City: | | State: | | Zip Code: | | | Phone: | (Home)
| | (Business) | | (Cell)
| | Relationship: | | | Email: | | |
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By signing below, I grant permission for Hillcrest staff to transport me to the nearest hospital, physician, or emergency room in the event of a medical emergency. I understand that if the Charge Nurse determines the need for emergency personal to be contacted, I may be transported via ambulance at my expense.
(This agreement expires upon discharge)
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