JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Make an Appointment
Hacer una cita
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Patient Status
*
Existing Patient
New Patient
Clinic Location
*
Choose
Calexico Wellness Center
San Bernardino Mdpoint Community Clinic
San Diego Clinic
First Name
*
Your answer
Last Name
*
Your answer
Email/Correo Electrónico
*
Your answer
Phone number/Número de Teléfono
*
Your answer
Social Security
Your answer
Insurance
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Occupation
*
Your answer
Race
*
Choose
White
Black/African American
Chinese
Filipino
Vietnamese
Pacific Islander
Korean
Japanese
American Indian
Native Hawaiian
Asian Indian
Unknown
Decline to specify
Ethnicity
*
Hispanic
Not Hispanic
Decline to specify
Unknown
Birth Sex
*
Male
Female
Gender Identity
*
Male
Female
Transgender Male
Transgender Female
Non-binary
Other
Choose not to disclose
Sexual Orientation
*
Straight
Lesbian or Gay
Bisexual
Choose not to disclose
Other
Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Household Size
*
Choose
1
2
3
4
5
6 or more
Total Household Income
*
Choose
No Income
Less then $35,000
$36,000 - $50,000
$51,000 - $74,000
$75,000 - $100,000
$150,000 or more
Homeless/Limited Shelter Status
*
Homeless
Limited Shelter (Sleeping in Car or someone's sofa etc.)
N/A
How quickly can you get an appointment with your Primary Care Provider?
*
Same Day
Within the week
Within the month
Beyond the month
Other:
When was the last time you saw a doctor
*
Your answer
How confident are you that your Primary Care Provider will be available when you need them?
*
Not Confident
1
2
3
4
5
Very Confident
Questions/Preguntas
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Calexico Wellness Center.
Report Abuse
Forms
