Demographics Form | Ocracoke Health Center

Patient Information

Patient Name*

First Last

Patient Preferred Name*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Street Address Address Line 2 City State ZIP Code

Primary Telephone Number*

Secondary Telephone Number

Email*

Social Security Number

Date of Birth*

Sex at Birth*

(check what applies)

Male
Female

Gender Identity*

(check what applies)

Sexual Orientation*

(check what applies)

Marital Status*

(check what applies)

Race*

(check what applies)

Ethnicity*

(check what applies)

Hispanic or Latino
Not Hispanic or Latino
I Choose Not to Disclose

Language Preference*

(check what applies)

English
Spanish

Highest Level of Education*

(check what applies)

Less than High School degree
High School diploma or GED
More than High School
I Choose Not to Answer this Question

Patient Occupation*

Patient is a Minor*

Yes
No

Patient is a Seafood Worker*

Yes
No

Annual Household Income*

(check what applies)

How many family members, including yourself, do you currently live with?*

Emergency Contact*

First Last

Phone Number*

Relationship to Patient*

Person Financially Responsible if Not Patient

First Last

Phone Number

Relationship to Patient

Address

Street Address Address Line 2 City State ZIP Code

What is Your Main Insurance?*

(check all that apply)

None/uninsured
Medicare
Medicaid
BCBS
Medcost
Tricare
United Health Care
Other Private Insurance

Insurance Policy / Member ID

Group ID

File Upload - Upload Pictures of Insurance Card, front and back, and Your Drivers License (front)

Please take a picture of your of your insurance card (front & back ). Please take a picture of your Drivers License (front). You can upload all the images here.

Drop files here or

Signature*

Date*

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Patient Information

Ocracoke Health Center

Engelhard Medical Center

Hours