Epstein Secrets

LY PHYSICIAN (413) PHYSICIAN PHONE µe7 Does your child currenV have health insurance? BYES 0 NO If YES, indicate: (07) HOSPITAL PREFERENCE . 0 Medicaid airivate 0 Healthy Kids/Kid Cam 0 Interested in receiving information eittiS •i p ER, tpl.PeEtliii,„_, ,,,,,_ cfrk oil _ ,§q. ,pp 73, (49) NA

name) (apt. no) (ulY) (stale) MP 0,(0!) BO SOCIAL SECURITY NO. Toptrone0 (9) HOME TELEPHONE NO. (10) F 1 (11)RACFJETHMC ORIGIN y • Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 W-White, Non-Hispanic 0 M-Multiracial I-American Indian/Alaskan • A-Asian/Pacific Islander (12) DATE OF MTH (leAUDD

Y PHYSICIAN (46) PHYSICIAN PHONE (48) Does your child currently have health insurance? MI YES 0 NO If YES, indicate: (47) HOSPITAL PREFERENCE 0 Medicaid 0 Private 0 Healthy Kids/kQd Care 0 Interested In receiving information ASWALOA491.4:04iiit lit filierAlaffiblikr0S-1-101)1; . .. (49) NAME CF

RITY NO.PAPLOneg (I) HOME TELEPHONE NO. (10) S 1 F (I1) RACErETNNIC ORIGIN 0 I-American Indian/Alaskan 0 A-Asian/Pacific Islander W . Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 NI-Multiracial • W-VVhite, Non-HiSpanic (12) DATE OF BIRTH M TMARDCWYY (13t PLACE OF BIRTH (c4 stab. couphy) WEST

um fluoride program (Permission is valid (hmugh grade 6) YES (27) Does your child currently have health insurance? 0 YES 0 NO If YES, indicate: 0 Medicaid 0 Healthy Kids/Kid Care 0 Private (29) NOME LANGUAGE SURVEY (Chock so that Appy) 0 A language other than English Is used in the home. 0 The stude

(ophone0 (9) HOME TELEPHONE NO. (12) DATE Of MTH (13) MACE OF BIRTH (city, LS ceneery) (11MAXWYYY) (1C) SE:1 F (11) RACE/Ell-RICORIGIN Native 0 B-Black, Non-Hispanic 0 W-White, Non-Hispanic • I-American Indian/Alaskan • H-Hispanic 0 A-Asian/Pacific Islander 0 M-Multiraclal (14) 0 RESIDENT STA