High Horizon West Hempstead, NY Form

Patient First Name:

Patient Middle Name:

Patient Last Name:

Email:

Date:

Date of Birth:

Home Phone:

Cell Phone:

Address (Street):

Address (City):

Address (State):

Address (Zip):

Gender:

Male Female

This is a Federal government requirement that we ask these questions.

Race:

Caucasian Black/African American Asian Native American Other Decline

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Decline

Sexual Orientation: