Patient Application Do you have private insurance?* Yes No Do you have Medicaid, Medicare, or Veteran's Insurance?* Yes No How did you hear about Genesis Community Health?* Healthcare provider Friend or relative Postcard/Mail Internet Search Radio Event Social Media Which Event?* Best Phone number to reach you?*At which Genesis Community Health clinic location would you like to be seen?* Garden City Location Caldwell Location Name* First Last Date of Birth* Month Day Year Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email What is your current medical and/or dental complaint?*(Note: Genesis patients are encouraged to utilize both Medical and Dental resources to better maintain their overall health.)What other medical conditions do you have or have been diagnosed with?HiddenDo you have any history of depression /anxiety / bipolar /ADHD /ADD and/or other mental illnesses? If other please fill in below: Depression Anxiety Bipolar ADHD ADD Do you have any history of depression /anxiety / bipolar /ADHD /ADD and/or other mental illnesses? (check one) If other please fill in below: Depression Anxiety ADHD ADD Other Other mental illnesses: Have these conditions been diagnosed by a doctor? Yes No Are these conditions controlled? Yes No What medications are you taking? Prescribed by? When was the last time you were seen by a medical professional? Month Day Year What clinic were you seen in? Have you been in the ER in the last 6 months? Yes No If yes, which hospital and city?* How many people are in your household? (Yourself and anyone claimed on taxes)*Please enter a number from 1 to 10.What is your Household Annual Income?*Of the people in your household how many are over 18?*123456Gather one of the following financial documents for all members of your household 18 or older (that you would claim on your taxes). Last year’s tax return/ W-2 1 month of recent paystubs If private business owner, 1 year’s profit and loss statement Upload Required Documents For Person 1*Max. file size: 512 MB.Upload Required Documents For Person 2*Max. file size: 512 MB.Upload Required Documents For Person 3*Max. file size: 512 MB.Upload Required Documents For Person 4*Max. file size: 512 MB.Upload Required Documents For Person 5*Max. file size: 512 MB.Upload Required Documents For Person 6*Max. file size: 512 MB.EmailThis field is for validation purposes and should be left unchanged. Δ
