Clinic By The Bay Referral Form
First Name
Last Name
Gender
Please Select
Male
Female
Transgender
Other
Marital Status
Please Select
Single
Married
Domestic Partner
Divorced
Widowed
Other
Date of Birth (mm/dd/yyyy)
Birth Country
Primary Lang.
Please Select
English
Spanish
Cantonese
Mandarin
Tagalog
Other
Ethnicity
Please Select
African American
Asian/Pacific Islander
Caucasian
Hispanic/Latino
Native American
Unknown/Declines to State
Other
Address 1
Addr. 2
City
Please Select
Daly City
San Francisco
Other
State
Zip
Time at Address
Please Select
Under 30 days
1-12 months
1-3 years
Over 3 years
Phone
-
Area Code
Phone Number
Cell?
Please Select
Yes
No
Msg OK
Please Select
Yes
No
Alt Phone Number
-
Area Code
Phone Number
Alt Cell?
Please Select
Yes
No
Alt Msg OK
Please Select
Yes
No
Text msg OK
Please Select
Yes
No
E-mail
Preferred Contact Method
Please Select
Phone
Email
Health Insurance Information
Provider
Please Select
* None *
MediCal
MediCare
Healthy Families
Other
Coverage
ACE?
Please Select
Yes
No
Healthy SF?
Please Select
Yes
No
Home
Coverage
Primary Care
Mental Health
Dental Care
Vision Care
Hospital Only
Prescr. Drugs
Other Coverage
Comments
Employment and Household Information
Employer / Occupation
Number in Household
Weekly HH Income
Total HH Assets
Household Members (Not including Applicant)
Person 1
First Name 1
Last Name 1
Relationship 1
Please Select
Spouse
Dom. Partner
Child
Parent
Other Relation
Other Non-Relative
Date of Birth 1 (mm/dd/yyyy)
Age 1
Person 2
First Name 2
Last Name 2
Relationship 2
Please Select
Spouse
Dom. Partner
Child
Parent
Other Relation
Other Non-Relative
Date of Birth 2 (mm/dd/yyyy)
Age 2
Person 3
First Name 3
Last Name 3
Relationship 3
Please Select
Spouse
Dom. Partner
Child
Parent
Other Relation
Other Non-Relative
Date of Birth 3 (mm/dd/yyyy)
Age 3
Person 4
First Name 4
Last Name 4
Relationship 4
Please Select
Spouse
Dom. Partner
Child
Parent
Other Relation
Other Non-Relative
Date of Birth 4 (mm/dd/yyyy)
Age 4
Referral Information
Referrer
Phone Number
-
Area Code
Phone Number
Referrer E-mail
Agency
Referrer Comments
How Heard about CBTB
Please Select
Brochure/Poster/Flyer
Website
Walk-in
Referral Agency
Word-of-mouth
Media
Outreach event
Other
Last Doctor Visit
Please Select
<1 year
1 - 3 years
3 - 5 years
5 - 7 years
7 - 10 years
> 10 years
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