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Includes demographic details (name, date of birth, sex, preferred language), contact information, addresses, interpreter and veteran/disability questions, marital status, race and ethnicity. Captures emergency contact, partner details, household members and dependents, insurance identifiers, and employment history related to agricultural work. 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Yes No Do you Prefer to be called or texted? Call-Text-Both  \nPhysical Address:   Apt/Trailer \\#  City   State   Zip Code   Mailing Address:   City   State   Zip Code    \nPreferred Language: English-Spanish-Other:   Interpreter Needed? Yes / No Are you a veteran? Yes / No Do you have a disability? Yes / No  \nMarital Status: Single-Married-Partner-Widowed-Divorced-Decline to answer  \nRace: White-More Than One-Asian-Black/African American-Native American-Native Hawaiian or Pacific IslanderOther  -Decline to answer  \nEthnicity: Hispanic/ Latinx-Non Hispanic or Latinx-other  -Decline to answer  \nEmergency Contact: Name:   Phone: Home/Cell:    \nRelationship to you:    \nYour Insurance Name:   Member ID:   Group ID:    \nPartner Name-Single-First Name   Last Name   DOB   Sex: M/ F Phone Number:    \nRace: White-More Than One-Asian-Black/African American-Native American-Native Hawaiian or Pacific IslanderOther  -Decline to answer  \nEthnicity: Hispanic/ Latinx-Non Hispanic or Latinx-other  -Decline to answer  \nPartner’s Medical Insurance Name:   ID \\#   Partner’s Dental Insurance Name:   ID\\#    \nHousehold Members and Dependents Not Including You or Your Partner: -N/A- : Total \\# of Members in Household:   \nName:   Sex: M/ F DOB:   Relation to you:   Insurance Name:   Insurance ID:    \nName:   Sex: M/ F DOB:   Relation to you:   Insurance Name:   Insurance ID:    \nName:   Sex: M/ F DOB:   Relation to you:   Insurance Name:   Insurance ID:    \nName:   Sex: M/ F DOB:   Relation to you:   Insurance Name:   Insurance ID:    \nName: ______________________________________________________ Sex: M/ F DOB: ___________________ Relation to you: _________________  \nInsurance Name:______________________________________________ Insurance ID: ____________________________________________________  \nName: ______________________________________________________ Sex: M/ F DOB: ___________________ Relation to you: _________________  \nInsurance Name:______________________________________________ Insurance ID: ____________________________________________________  \nIntake Form Page 1 of 1  \nPatient Intake Form Continued  \nEmployment  \nHave you or anyone in your household worked in agriculture in the last 24 months or retired from agricultural work? Yes / No If Yes, who in your household is employed in agricultural work?  \nName:   Relationship to you:    \nWhat type of Ag Worker? Seasonal Farmworker-Migrant Farmworker (Temporary home) -Retired Farmworker Type of Work in Agriculture or on Farm?: Crops-Livestock-Nursery-Other:    \nName of Employer for Agricultural Work:   H2A Visa Worker? Yes / No Address:   City:   State:   Zip Code:    \nDates of Employment:   to    \nCurrent Employment: Full-time-Part-Time-Unemployed-Retired Are you a Student? Yes / No  \nOccupation:   Second Occupation: N/A    \nYour Current Employer Name:   Unemployed-Self-Employed  \nAddress   City   State   Zip Code   \nPartner’s Current Employment: Full-Time-Part-Time-Unemployed-Retired Are you a Student?  \nOccupation:   Second Occupation: N/A    \nEmployer Name:   -Self-Employed  \nAddress   City   State   Zip Code  Estimated Annual Household Income For Previous Year (Including Partner): $   -Unemployed  \nIf you were unemployed last year, what is your estimated income for this year?: $   \nType of Income Verification Provided? Recent Pay Stubs-1040 Tax Form-W2-Employee Letter-Not Provided  \nBy signing this document, you acknowledge that the information above is correct to the best of your knowledge. You also acknowledge that it is your responsibility to notify Ag Worker Health and Services when you have any changes in the information provided above.  \nDate  \nRelationship to patient  \nIntake Form Page 2 of 2  \nName:  DOB:  \nConsent Form  \n________________  \nConsent to receive Healthcare Services  \nBy signing this document, I hereby","cbCaigVusdgMfVcu","https://ap.wps.com/l/cbCaigVusdgMfVcu","pdf",1226978,7,"English","# Patient Intake Form\n## Consent Form","[{\"question\":\"What information is requested in the patient intake section?\",\"answer\":\"The form collects demographic details, contact information, addresses, interpreter needs, veteran and disability status, marital status, race and ethnicity, emergency contact, partner information, household dependents, and insurance member/group identifiers.\"},{\"question\":\"Does the intake form ask about agricultural work history?\",\"answer\":\"Yes. It asks whether the patient or household worked in agriculture in the last 24 months or retired from agricultural work, including details about the type of ag worker, employer, visa status, addresses, and employment dates.\"},{\"question\":\"What does the consent form cover?\",\"answer\":\"It provides consent to receive medical, behavioral health, dental, and preventive services, and includes acknowledgement of Notice of Privacy Practices and authorization/choices for verbal communication and how the clinic can contact the patient.\"}]","Patient Intake Form - Registration Packet | PDF",1789791208]