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Patient Demographic Information
Last Name *
Enter PATIENT last name and suffix, if applicable
Your answer
First Name *
Enter PATIENT first name. Do not enter middle name or middle initial
Your answer
DOB *
Enter PATIENT date of birth
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Race *
Which of the following best describes your race? Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information
Ethnicity *
Which of the following best describes your ethnic group? Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information.
Gender *
Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information.
Street Address *
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City *
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State / *
Use only 2 letter abbreviation (i.e. NY)
Your answer
Zip Code *
Please enter 5 digit zip code
Your answer
County *
Your answer
Phone *
Please use mobile phone number (in the event of a positive). Valid Format: 555-555-5555
Your answer
Pregnant or Post Partum *
Primary Care Provider *
Full Name, Phone Number
Your answer
Are You A Student or An Employee Of A School District? *
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