POE Form

Are you registered to vote?
Do you have a primary care physician?
If yes, give the physicians name:
Are you pregnant?
Are you American Indian?
Are you a Catawba Mental Health Patient?
Patient Name(Required)
Date(Required)

Primary Phone(Required)
Type
Ok to leave a message?
Phone #3(Required)
Type
Ok to leave a message?
Phone #2(Required)
Type
Ok to leave a message?

DOB(Required)

Address
Mailing Address (If different than physical address):

Gender Identity
Tobacco
Gender
Smoking Status
Race
Primary Language
Ethnicity
Need Interpreter
Marital Status
Military Status

Employment Information

Employment Status
If Not in Labor Force, why?

Education

Household Information

Principal Income Source
Do you plan to apply for Financial Assistance?
Be prepared to supply staff with Proof of Residency, 2 recent check stubs, last signed Fed/State tax return, Social Security eligibility letter, proof of other income, proof of dependents. Call 803-325-1800 for more information.

Emergency Contact

Name
Address
Phone
Ok to leave a message?