Patient registration form (revised 4/18/22)

Name *

First

Last

Nickname or name you prefer to be called

Date of Birth *

Social Security Number *

If you have no social security number, enter 00000.

Where do you live? *

Address *

City *

State *

Zip Code *

Email Address *

Phone you use most *

Cell Phone

Work Phone

Preferred Method of Contact

Home Phone
Cell Phone
Text
Email

Sex

Male
Female
Other

Sexual Orientation

How did you hear about Bradley Free Clinic? *

If "Other," then how did you hear about us?

Gender Identity

I have a driver's license or other valid government-issued ID.

Yes
No

Photo ID (Front) *

Click or drag a file to this area to upload.

Upload the front of your driver’s license or government ID.

Parent / Legal Guardian

Occupation

I am *

Employed in a job that does not offer a health insurance plan
Employed but unable to afford my employee offered plan
Employed with health insurance that does not cover some services I need
My employer does not provide documentation of my pay
Unemployed
Disabled
Working as an unpaid caregiver for children, disabled, or elderly.

I am employed *

Full Time
Part time

Estimated monthly gross income *

Proof of income for the last 30 days. Upload pay stub(s) to support that amount

Click or drag a file to this area to upload.

Upload pay stub #2

Click or drag a file to this area to upload.

Upload pay stub #3

Click or drag a file to this area to upload.

Upload pay stub #4

Click or drag a file to this area to upload.

Upload your previous year's IRS 1040 form

Click or drag a file to this area to upload.

Marital Status

Are you a:

US Citizen
US Resident
Other

Number of Dependents (spouse and children), including self. *

Are you a United States Military Veteran?

Yes
No

What is your primary language

Do you require an interpreter?

Yes
No

Race (check all that apply)

Ethnicity

Hispanic
Non-Hispanic

Phone Contact Permission – Name of contact

List person/persons whom the Bradley Free Clinic may contact in the event you are not able to speak or in the event of an emergency.

Contact relationship to the patient

Contact phone

Alternate contact name

Alternate contact phone

Please choose

I have no health insurance
I recently lost my employer-paid insurance
I have employer-paid or private health insurance

Do you have any form of insurance? If so, what?

Do have Medicaid? If so, please upload your cards below.

Yes
No

If you have Medicaid, upload front of card

Click or drag a file to this area to upload.

If you have Medicaid, upload back of card

Click or drag a file to this area to upload.

If you have Medicaid, upload the front of your carrier card (such as Anthem, Virginia Premiere or Magellan) here

Click or drag a file to this area to upload.

If you have Medicaid, upload the front of your carrier card (such as Anthem, Virginia Premiere or Magellan) here

Click or drag a file to this area to upload.

Initial here

HEALTH HISTORY

Why did you make this appointment?

Regular checkup
First appointment to start care with a new doctor
Switching doctors
Have a specific health problem

If you are switching doctors, from whom?

If you have a specific health issue, please explain

Are you taking any prescription medicines?

Yes
No

Name of Pharmacy

Phone number

If yes, list name of medication, amount/pill size, how many doses you take and what time of day.

What over-the-counter medicines (medicine you do not need a prescription for) do you take regularly?

Please list any vitamins, herbal supplements or other that you take.

Do you get an allergic reaction (bad effect) from any of the following? (Check all that apply)

Allergies to medicines

If you have a known allergy to any medicine or medicines please list them and describe the effects.

If you have other allergies, please list them

Have you ever been a patient in a hospital overnight?

Yes
No

If yes list the reason why and when you were in the hospital. Please list all hospital overnight stays.

Have you ever had a colonoscopy (a test to look at your insides by sending a camera through your bottom)

Yes
No

If you have had a colonoscopy, when and where?

When was your last tetanus shot?

When was your last pneumonia shot?

When was your last flu shot?

Do you smoke cigarettes, cigars, use snuff, chew tobacco or vape?

Yes
No

If yes, when did you start and how much per week?

Do you drink alcohol?

If yes, how many drinks do you have in a typical week?

Do you use anything to help you walk?

Yes
No

If so, what do you use?

Do you feel safe in your home? *

Yes
No

Do you need help with child care items such as car seat, crib, diapers, formula or other needs? *

Yes
No

Do you have trouble paying for housing, electricity, or food? *

Yes
No

Do you ever been in jail or prison? *

Yes
No

Do you need help with transportation? *

Yes
No

Do you need a job? *

Yes
No

Have you ever had any of the following? (check all that apply)

If you have experienced other medical conditions, please list them here

FOR WOMEN ONLY

Have you ever been or are you currently pregnant?

Yes
No

If yes, how many times?

How many children have you given birth to?

Do you use birth control (the pill, condoms, intrauterine device, Nexplanon)?

Yes
No

If yes, which kind?

Have you had a PAP smear?

Yes
No

Date of last one

Where?

Were there any abnormalities in your PAP smear? If so, what?

Have you had a mammogram (breast x-ray)?

Yes
No

Date of last one

Where?

ACKNOWLEDGEMENTS AND AUTHORIZATION

CONSENT FOR TREATMENT

Initials for CONSENT FOR TREATMENT

NO GUARANTEE

Initials for NO GUARANTEE

RELEASE OF INFORMATION

Initials for RELEASE OF INFORMATION

CONSENT TO TREATMENT BY MEDICAL STUDENTS

Initials for CONSENT TO TREATMENT BY MEDICAL STUDENTS

CONSENT TO RECEIVE VOICEMAILS & TEXT MESSAGES

Initials for CONSENT TO RECEIVE VOICEMAILS & TEXT MESSAGES

PATIENT ASSISTANCE PROGRAMS (PAP)

Initials for PATIENT ASSISTANCE PROGRAMS (PAP)

I UNDERSTAND THAT:

Initials for I UNDERSTAND THAT:

I FURTHER UNDERSTAND THAT

Initials for I FURTHER UNDERSTAND THAT:

CERTIFICATION AND ACKNOWLEDGEMENT

Initials for CERTIFICATION AND ACKNOWLEDGEMENT

Patient or Parent/Legal Guardian

Relationship to Patient

Date *

Witness Signature

HIPAA Release of Information

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

24 Hour Cancellation & "No Show" Penalty Policy

Medical Cancellation

Dental Cancellation

Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients.

Patient's Name

Initials

Date

BFC Staff/Screener Name

BFC Staff/Screener Signature

Date

DENTAL HEALTH HISTORY

Name *

First

Last

Today's Date *

Birthdate *

Sex

Male
Female

When was your last dental visit?

What was the reason for your last visit?

Do you brush daily?

Yes
No

How many times per day?

Do you floss daily?

Yes
No

How many times per day?

Do you have a specific dental problem or concern?

How would you rate your current dental health?

Good
Fair
Poor

Are you currently in discomfort?

Yes
No

Have you been to the ER in the last year for dental issues?

Yes
No

If yes, when and where did you go?

Have you gone to the ER several times for the same problem?

Yes
No

If yes, how many times?

Do you have Osteoporosis?

Yes
No

Do you have a history of taking Bisphosphonates? (Bisphosphonates are prescription drugs that are commonly used to treat Osteoporosis, like Boniva or Fosamax)

Yes
No

Do you require antibiotic pre-medication prior to dental work?

Yes
No

Do you have food sensitivity to

Informed Consent for Integrated Care Services

Date *