Patient DOB:	___ / ___ / ______
Patient ethnicity:	___Hispanic
	___Non-Hispanic
	___Undocumented
	___Documented as “not known”
Patient race:	___White
	___Black/African American
	___Asian
	___Pacific-Islander
	___Native American/Alaska Native
	___Other: __________________________________________
	___Undocumented
	___Documented as “not known”