Date of Upcoming Appointment (if known) Are you an existing Southcoast Health patient? Yes No Patient Information First Name Last Name Date of Birth Gender Select Gender Female Male Unknown/Other Medical Record Number (if known) Home Address Home Zip Code Is Home Address different than Mailing Address? Yes No Mailing Address Mailing Zip Code Cell Phone Home Phone Email Address Primary Care Physician Preferred Language Select Preferred Language English Spanish Portuguese Cape Verdean Creole Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Armenian Aymara Azerbaijani Bashkir Basque Bengali Bislama Bosnian Breton Bulgarian Burmese Catalan Central Khmer Chamorro Chinese Corsican Croatian Czech Danish Dutch Esperanto Fijian Finnish French Georgian German Greek Guarani Gujarati Haitian Hausa Hebrew Hindi Hmong Hungarian Icelandic Igbo Indonesian Interlingua (International Auxiliary Language Association) Irish Italian Japanese Javanese Kalaallisut Kannada Kashmiri Kinyarwanda Korean Kurdish Lao Latin Latvian Lingala Lithuanian Malay Malayalam Marathi Mongolian Napoli Navajo Nepali Norwegian Bokmål Norwegian Nynorsk Occitan Ojibwa Oriya Oromo Panjabi Patient Refused Persian Polish Portuguese (Brazilian) Portuguese (Cape Verdean) Portuguese (Continental/Azorean) Pushto Quechua Quiche-Mayan Romanian Romansh Rundi Russian Samoan Sango Sanskrit Serbian Shona Sign Language Sindhi Sinhala Slovak Somali Southern Sotho Sundanese Swahili Swedish Tagalog Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Islands Tsonga Tswana Turkish Turkmen Twi Ukrainian Urdu Uzbek Vietnamese Welsh Wolof Xhosa Yiddish Yoruba Zulu Other Other Language Written Language Select Written Language English Spanish Portuguese Cape Verdean Creole Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Armenian Aymara Azerbaijani Bashkir Basque Bengali Bislama Bosnian Breton Bulgarian Burmese Catalan Central Khmer Chamorro Chinese Corsican Croatian Czech Danish Dutch Esperanto Fijian Finnish French Georgian German Greek Guarani Gujarati Haitian Hausa Hebrew Hindi Hmong Hungarian Icelandic Igbo Indonesian Interlingua (International Auxiliary Language Association) Irish Italian Japanese Javanese Kalaallisut Kannada Kashmiri Kinyarwanda Korean Kurdish Lao Latin Latvian Lingala Lithuanian Malay Malayalam Marathi Mongolian Napoli Navajo Nepali Norwegian Bokmål Norwegian Nynorsk Occitan Ojibwa Oriya Oromo Panjabi Patient Refused Persian Polish Portuguese (Brazilian) Portuguese (Cape Verdean) Portuguese (Continental/Azorean) Pushto Quechua Quiche-Mayan Romanian Romansh Rundi Russian Samoan Sango Sanskrit Serbian Shona Sign Language Sindhi Sinhala Slovak Somali Southern Sotho Sundanese Swahili Swedish Tagalog Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga Islands Tsonga Tswana Turkish Turkmen Twi Ukrainian Urdu Uzbek Vietnamese Welsh Wolof Xhosa Yiddish Yoruba Zulu Other Other Language Ethnicity Select Ethnicity Afghanistani African African American American Argentinean Armenian Asian Asian Indian Assyian Bangladeshi Barbadian Bhutanese Bolivian Botswanan Brazilian Burmese Cambodian Canarian Cape Verdean Caribbean Island Central American (Other) Central American Indian Chicano Chilean Chinese Columbian Costa Rican Criollo Cuban Dominica Islander Dominican Eastern European Ecuadorian Egyptian Ethiopian European European English European-French European-German European-Irish European-Italian European-Scottish Guatemalan Haitian Hispanic or Latino Hmong Honduran Indonesian Iranian Iraqui Israeli Filipino Jamaican Japanese Korean La Raza Laotian Lebanese Liberia Madagascar Malaysian Maldivian Mexican Mexican American Middle Eastern/North African Namibian Nepalese Nicaraguan Nigerian Not Hispanic or Latino Pakistani Palestinian Panamanian Paraguayan Patient Refused Peruvian Polish Portuguese Puerto Rican Russian Salvadoran Singaporean South American (Other) South American Indian Sri Lankan Syrian Taiwanese Thai Tobagoan Trinidadian Unknown/Not Specified Uruguayan Venezuelan Vietnamese West Indian Zairean Prefer not to Answer Other Other Ethnicity Race Select Race American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Other Pacific Islander Patient Refused White or Caucasian Prefer not to Answer Other/Not Specified Other Race Marital Status Select Marital Status Divorced Legally Separated Married Significant Other Single Widowed Other Other Marital Status Employment Status Select Employment Status Disabled Full Time Not Employed On Active Military Duty Part Time Retired Self Employed Student - Full Time Student - Part Time Job Title Employer Name Employment Address Zip Code Work Phone Financial Responsibility Who will be financially responsible for your medical expenses? Select Option Patient Motor Vehicle Accident Personal Injury Worker's Compensation Other Name Relationship to Patient Select Relationship to Patient Aunt Brother Daughter Employer Father Friend Granddaughter Grandfather Grandmother Grandson Legal Guardian Mother Self Sister Son Spouse Step Father Step Mother Uncle Other Other Relationship to Patient Date of Birth Address Zip Code Phone Number Employment Status Select Employment Status Disabled Full Time Not Employed On Active Military Duty Part Time Retired Self Employed Student - Full Time Student - Part Time Place of Employment Employment Address Zip Code Employment Telephone Number Occupation Insurance Information Do you have Insurance? Yes No Insurance Type Insurance ID Number if applicable include letters and numbers Is Subscriber different than Patient? Yes No Subscriber Name Subscriber Address Subscriber Zip Code Subscriber Phone Subscriber Gender Select Subscriber Gender Female Male Unknown/Other Subscriber Date of Birth Subscriber Employer Relationship to Patient Select Relationship to Patient Adopted Child Brother or Sister Brother-in-law or Sister-in-law Cadaver Donor Child Child Where Insured Has No Financial Responsibility Collateral Dependent Court Appointed Guardian Cousin Dependent of a Minor Dependent Emancipated Minor Employee Ex-spouse Father Foster Child Grandfather or Grandmother Grandson or Granddaughter Guardian Handicapped Dependent Injured Plaintiff Life Partner Mother Mother-in-law or Father-in-law Niece or Nephew Organ Donor Parent Self Significant Other Son-in-law or Daughter-in-law Sponsored Dependent Spouse Stepfather Stepmother Stepson or Stepdaughter Uncle or Aunt Ward Other Adult Other Relationship Do you have a Secondary Insurance? Yes No Type of Secondary Insurance Type Insurance ID Number if applicable include letters and numbers Is Subscriber different than Patient? Yes No Subscriber Name Subscriber Address Subscriber Zip Code Subscriber Phone Subscriber Gender Select Subscriber Gender Female Male Unknown/Other Subscriber Date of Birth Subscriber Employer Relationship to Patient Select Relationship to Patient Adopted Child Brother or Sister Brother-in-law or Sister-in-law Cadaver Donor Child Child Where Insured Has No Financial Responsibility Collateral Dependent Court Appointed Guardian Cousin Dependent of a Minor Dependent Emancipated Minor Employee Ex-spouse Father Foster Child Grandfather or Grandmother Grandson or Granddaughter Guardian Handicapped Dependent Injured Plaintiff Life Partner Mother Mother-in-law or Father-in-law Niece or Nephew Organ Donor Parent Self Significant Other Son-in-law or Daughter-in-law Sponsored Dependent Spouse Stepfather Stepmother Stepson or Stepdaughter Uncle or Aunt Ward Other Adult Other Relationship Emergency Contact Name Address Zip Code Relationship to Patient Select Relationship to Patient Adoptive Parent Aunt Babysitter Brother Care Giver Case Worker Daughter Ex-Husband Ex-Wife Father Financial Guarantor Foster Parent Friend Godfather Godmother Grandchild Grandparent Legal Guardian Mother Neighbor Parent Relative Roommate Sibling Significant Other Sister Social Worker Son Sponsor Spouse Step Parent Surrogate Uncle Other Other Relationship to Patient Cell Phone Home Phone Submit Submitting... 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