Vista Community Clinic Pre-Registration

Holiday Homes Tour - Dec 7th

Proceeds benefit our Kare for Kids program.

PRE-REGISTRATION FORM

Last Name:
First Name:
Middle Initial:
Sex:	Female Male
Date of Birth:
Social Security Number:
Marital Status:	Married Divorced Separated Single Widowed
Preferred Language:
Street Address:
City:
State:
Zip:
Contact Phone Number:
Employer:
Employment Address:
Employment City:
Employment State:
Employment Zip:
Work Phone Number:
Email Address:
Emergency Contact Person:
Emergency Contact Phone Number:
Emergency Contact Address:
Emergency Contact City:
Emergency Contact State:
Emergency Contact Zip:
I have insurance:	Yes No
Primary Insurance Company Name:
Policy Holder First Name:
Policy Holder Last Name:
Policy Holder Relationship to Patient:	Patient Spouse Dependent Child Grandchild Significant Other Other
Policy Holder Date of Birth:
Policy Holder Social Security #:
ID Number:
Group Name:
Group Number:
ADDRESS TO MAIL CLAIMS (usually listed on your card)
City:
State:
Zip: