PCHS Demographic Form

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* 1. Last Name

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* 2. First Name

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* 3. Date of Birth

Date

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* 4. Sex at Birth

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* 5. Address

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* 6. Consent to Call

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* 7. Text Message ok?

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* 8. Insurance

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* 9. If uninsured and you would like to be contacted about how to apply for slide scale or insurance, please check the box.

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* 10. Billing Authorization
Please read the statements below. Check each box (last box for Medicare recipients only)
Enter your name and date to provide authorization.

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* 11. Name

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* 12. Date 

Date

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* 13. Select the box below if you would like to receive a copy of the Patient Rights and Responsibilities

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