Patient Registration Form Patient Information Gender Identity FemaleMaleTransgender Female to MaleTransgender Male to FemaleOtherChoose Not to Disclose Sexual Orientation StraightLesbian or GayBisexualOtherDon't KnowChoose Not to Disclose Housing Status Non-HomelessLiving in ShelterHomeless Transitional Housing UnitDoubled Up With OtherHomeless Living on Street or OutsideOtherUnknown Do You Live In Public Housing? YesNo Migrant Worker Status TrueFalse Seasonal Farm Worker Status TrueFalse Guarantor Information (If patient is a minor under 18 years of age) I agreedisagree with the following statement. As a patient, I consider St. George Medical Clinic as my medical home. A medical home is referred to as one facility where you receive continual care that is managed and coordinated by a personal clinician with your better health as the outcome. I authorize the release of medical information necessary to process all claims on my behalf. I hereby give authorization to St. George Medical Clinic to apply for benefits for covered services rendered to me. I authorize payment of medical benefits to St. George Medical Clinic for services rendered. I certify that the information I have provided is correct. I understand that I am responsible for any balance not covered by my insurance company. I authorize treatment by medical providers at St. George Medical Clinic as is medically necessary for my condition/illness.
