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Registration Form PLEASE PRINT (PATIENTS (CHILD) NAME) Male () Female PATIENTS SOCIAL SECURITY # DATE OF BIRTH ADDRESS CITY STATE ZIP CODE PHONE CELL WORK RACE ETHNICITY: () HISPANIC () HISPANIC MEDICAID

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3. Depending on the registration form, you may also be required to provide additional information such as your date of birth, gender, or occupation. Fill out these sections accordingly.
4. If the registration form includes a username and password section, choose a unique username and a strong password that is easy for you to remember but difficult for others to guess. Avoid using common passwords or those that can easily be associated with you.
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6. If the registration form requires you to agree to any terms and conditions or privacy policies, take the time to read them carefully. Only proceed if you fully understand and agree to the terms provided.
7. Once you have completed all the necessary fields, review the entire registration form to ensure all information is accurate and complete. Make any necessary corrections or additions.
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