Checkin Form

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Patient Check-in Form

← Return to Patient Forms Portal

Please complete and submit

Today's Date *

Please check all that apply:

Medicaid *

No Pending

Healthy MI *

No Pending

GHP *

No Pending

Is today's visit related to an injury/accident? *

Yes No

If yes *

Auto? Work? Home? Other?

* Indicates required field

First Name *

LAST NAME *

MIDDLE INITIAL *

Address *

Home Number *

Cell Phone *

Contact Person (Name) *

Phone Number *

City *

MI *

Zip Code *

Soc. Sec. No. *

Date of Birth *

Relationship *

List any alegies *

Other Allergies *

Latex Seafood Dairy Other

Other *

Housing *

Employment *

Marital Status *

Ethnicity *

Referred by *

Gender *

Male Female

U.S. Citizen *

Yes No

Permanent Resident of USA *

Yes No

Veteran *

Yes No

Number of people in your house supported by spouse *

Why did you come to the clinic today? *

Submit

PROVIDING HEALTHCARE TO THE UNDER SERVED

Home
About
Patient Form Portal
How you can support
Executive Board
Volunteer App
WISH LIST
Happenings

Patient Check-in Form

Please complete and submit

PROVIDING HEALTHCARE TO THE UNDER SERVED​

PROVIDING HEALTHCARE TO THE UNDER SERVED