Emergency Contact Information: We must be able to identify ourselves as HealthFirst. Name of contact: « Phone: « Relationship: « Insurance Information: Yes No « Do you, your parents, or guardian have any insurance coverage on you? If yes name of insurance company: Date of birth of card holder: Do you have a Family Doctor? (Circle one) Yes No« Do you have Dental coverage? (Circle one) «Yes No « Do you have a Dental Provider? (Circle one) Yes No « » You currently live with (Circle all that No-one Spouse Children Partner Roommate Parents« Income Information: Are you working? (Circle one) «Yes No Name of Company: « Date you started: « How many hours a week do you work? « How much do you earn an hour? « Average weekly tips received? « Do you receive money from any other source? (Circle one) Yes No« » If yes, how much a week? « What is the source of income? « If you are married, how many hours a week does your spouse work? « How much does your spouse earn an hour? «» How many people are supported by this income? Would you like to make a donation today? (Circle one) Yes No Amount you would like to donate? «»
Emergency Contact Information: We must be able to identify ourselves as HealthFirst. Name of contact: « Phone: « Relationship: « Insurance Information: Do you, your parents, or guardian have any insurance coverage on you? Yes No « If yes name of insurance company: Date of birth of card holder: Do you have a Family Doctor? (Circle one) Yes No« Do you have Dental coverage? (Circle one) «Yes No « Do you have a Dental Provider? (Circle one) Yes No « » You currently live with (Circle all that No-one Spouse Children Partner Roommate Parents« Income Information: Are you working? (Circle one) «Yes No Name of Company: « Date you started: « How many hours a week do you work? « How much do you earn an hour? « Average weekly tips received? « Do you receive money from any other source? (Circle one) Yes No« » If yes, how much a week? « What is the source of income? « If you are married, how many hours a week does your spouse work? « How much does your spouse earn an hour? «» How many people are supported by this income? Would you like to make a donation today? (Circle one) Yes No Amount you would like to donate? «»
Demographic%20Form.docx