Demographics Short Form

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Demographics Short Form
Please take a moment to fill out this form.
Note: If you prefer not to answer the question, or you are unsure of the answer, please check:
“Patient Declined/Unknown”
NAME:
DOB:
ETHNICITY:
Hispanic or Latino
Not Hispanic or Latino
Patient Declined/Unknown
RACE:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Patient Declined/Unknown
PREFERRED: This is the language by which you prefer to communicate:
LANGUAGE
English
Spanish
Other
Patient Declined/Unknown

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