HAAS
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HAAS
Holistic Array of Authentic Services
Providing high quality Homecare services
Step
1
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Personal Information
What is your legal first name? *
What is your middle name?
(Leave blank if not applicable)
What is your legal last name? *
What is your date of birth? *
What is your gender? *
Male
Female
Non-binary
How would you describe your ethnicity? *
Select an option
White/Caucasian
Black/African American
Hispanic/Latino
Asian
Native American/Alaska Native
Native Hawaiian/Pacific Islander
Other
What is your Social Security Number?
(You may leave this blank and provide it when you visit our office if preferred)
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(763)353-0136
5851 Duluth st, Suite #302, Golden Valley, MN 55442
Mon. — Fri. 9:00am-5:00pm