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Patient Signature Doc. NT-1206a Rev. 07/24/14 Date Page 1 of 1 2014 Aegis Treatment Centers LLC. All Rights Reserved.. REPLACEMENT NARCOTIC THERAPY ADMISSION Patient Section Clinic A. Name Identification and Contact Information 1. Legal Name First Name Last Name 2. Date of Birth 3. Gender 5. Social Sec No Middle Name Male Suffix Jr Sr. etc Nickname / Preferred 4. Aliases Female 6. Driver License State Number 7. Home Address City Street Address 8. Home Phone 9. Cell Phone 11. Eye Color 12. Hair Color 14. Referred By Zip Code 10. Email 13. Mother s Maiden Name Friends / Family Internet Search Doctor/Health Care Provider School / College Hospital 15. Race Self Referral Employer / EAP Provider Directory Other Alcohol/Drug Program Other/Community/Legal 12 Step White Alaskan Native Chinese Guamanian Japanese Laotian Vietnamese African American Asian Indian Filipino Hawaiian Korean Samoan Other Asian American Indian Cambodian Mixes Other Race 16. Tattoos Description/Location if multiple list at least 2 17. Distinguishing Marks B. Emergency Contact and Primary Physician 1. Contact Name 3a* Home Phone 2. Contact Address 4. Relationship Spouse Family Member Zip Friend Guardian Coworker Other 6. Phone 5. Primary Physician C. Financial / Employment Status 1. Method of Payment Self-Pay / Cash Medi-Cal Insurance VA County/Prop36 2. If Medi-Cal enter CIN Number 3. If Insurance complete following Insurance Carrier Member No 4. Employment status Full Time Part Time Unemployed Group No* Unemployed Not seeking Employer Name Never worked Volunteer Retired Work Phone Employer Address 5. Are you enrolled in School Yes No School Name Program / Major I certify that the information provided above is accurate to the best of my knowledge. REPLACEMENT NARCOTIC THERAPY ADMISSION Patient Section Clinic A. Name Identification and Contact Information 1. Legal Name First Name Last Name 2. Date of Birth 3. Gender 5. Social Sec No Middle Name Male Suffix Jr Sr. Legal Name First Name Last Name 2. Date of Birth 3. Gender 5. Social Sec No Middle Name Male Suffix Jr Sr. etc Nickname / Preferred 4. Aliases Female 6. Driver License State Number 7. Home Address City Street Address 8. etc Nickname / Preferred 4. Aliases Female 6. Driver License State Number 7. Home Address City Street Address 8. Home Phone 9. Cell Phone 11. Eye Color 12. Hair Color 14. Referred By Zip Code 10. Email 13. Mother s Maiden Name Friends / Family Internet Search Doctor/Health Care Provider School / College Hospital 15. Home Phone 9. Cell Phone 11. Eye Color 12. Hair Color 14. Referred By Zip Code 10. Email 13. Mother s Maiden Name Friends / Family Internet Search Doctor/Health Care Provider School / College Hospital 15. Race Self Referral Employer / EAP Provider Directory Other Alcohol/Drug Program Other/Community/Legal 12 Step White Alaskan Native Chinese Guamanian Japanese Laotian Vietnamese African American Asian Indian Filipino Hawaiian Korean Samoan Other Asian American Indian Cambodian Mixes Other Race 16.

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