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English to Spanish translations [PRO] Medical / hospitals
English term or phrase:ER
Usual Source of Primary Care: None Community Health Center School-Based Health Center
Family Planning Clinic Mobile Van Emergency Room Hospital Outpatient Physician/Clinic
Provider’s Name:_____________________________________________________________ Phone:_____________________
Address:________________________________________________________________ Date last seen:___________________
Seen in ER in the last year? Yes No Number of visits: ______
Reason for visit(s): ________________________
Do you have Dental Care? Yes No If Yes, please list Provider’s Name:_______
Source of Payment (circle one): Medicaid/Medicaid HMO Medicare Self-pay Private Insurance/HMO
If Medicaid Coverage:
Patient’s Medicaid State ID#:_________________________________________ County:____
Primary Care Physician Name:________________
¿Can it be "Sala de Emergencias"???