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SBHC ENROLLMENT FORM

STUDENT/PATIENT INFORMATION:

Gender
Ethnicity:
Race:
Language:
Sexual Orientation (If You Are 18 Years Or Older):
Marital Status:
Will The Patient Require A Translator:

Health History:

Select All That Apply:

Health/Dental Insurance
(Please give a current copy of card to receptionist):

Responsible Party
(If Patient Is Under 18 Years Of Age):

Thank you! Your form has been submitted.

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