Information Form - Health Department

* First Name

Middle Initial

* Last Name

* Street

Apartment #

* City

* State

* Zip

* Primary Phone Number

Alternate Phone Number

* Email Address

* Date of Birth

* Do you have health insurance?

Yes

* If yes, please provide the insurance details.

Insurance Name:

Policy Number (ID#):

Group Number:

* If no, please provide information about your government issued identification.

Drivers License or State ID

State

Drivers/State ID #

Country Passport

Country

Passport ID #

I do not have government-issued identification