Get Registration & Intake Form - For Health Fair & Immunizations - Centralcarechc

This guide provides step-by-step instructions on how to effectively complete the Registration & Intake Form for Health Fair and Immunizations at Central Care Community Health Center. Following these instructions will ensure that all necessary information is accurately submitted online, facilitating a smooth process.

Follow the steps to successfully complete the form.

1. Use the ‘Get Form’ button to access the Registration & Intake Form and open it in the provided interface.
2. Begin by entering the patient's name. Fill out the last name first, followed by the first name and middle initial, ensuring that the fields are accurately filled.
3. Input the date of birth in the specified field. This is crucial for determining eligibility for certain services.
4. Provide the last four digits of the social security number to help identify the patient.
5. Fill in the address, including the city, state, and zip code to ensure accurate location details.
6. Enter a telephone number and email address for contact purposes.
7. Select your ethnicity by marking the appropriate option for African American, Hispanic/Latino, Caucasian, or Asian.
8. Choose your marital status from the available options by selecting single, married, divorced, widowed, or other.
9. Indicate the screenings and immunizations you have chosen by marking the corresponding checkboxes.
10. Read through the disclaimer regarding the tests and results. This section outlines the responsibilities and rights of the participant. Ensure you understand its content.
11. Provide your printed name and sign the document, indicating your acknowledgment and consent.
12. If the participant is under age 18 or 16 and living independently, a parent or guardian must sign to give consent.
13. Lastly, review all the information filled out, save any changes made, and either download, print, or share the completed form as needed.

Complete your Registration & Intake Form online today for a seamless experience at the health fair and immunizations.