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Lesson 110 of 240

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Filling in the form in English

Ana is at Dr. Okafor's clinic across from the Blue Plate. A staff member gives her a form.

She looks at the boxes and does not know what to write. In the United States, date of birth is month, then day, then year.

You will ask what to write, check if you must sign, and hand over your insurance card.

If the card will not scan, you can say so in a short line.

By the end of this lesson

Ask what to write on a form, whether to sign, and what to do if a scan fails.

  • I'm not sure what to write here.You do not know which words go in this box.
  • Sign here.Write your name on this line.
  • Here's my insurance card.You give them the card from your health plan.
  • What's your date of birth?They ask the month, day, and year you were born.
  • Do I need to sign this?Ask if you must write your name on the form.
  • It won't scan.The machine cannot read the card.

Scene — the clipboard

The clinic across the street from the diner is quiet this morning. Ana stands at the front desk with a clipboard.

A staff member waits with a card reader. Dr. Okafor is in a room with pale walls and a high exam couch.

The form has empty boxes. Ana holds her insurance card and a pen.

Ana waits at the clinic front desk as Dr. Okafor is visible in the exam room.

Learn — what to write

Six short lines help you fill a clinic form.

You will ask what to write, sign your name, and say when a card will not scan.

  1. Ana looks down at an empty box on the form with her pen poised above it.

    I'm not sure what to write here.

    You do not know which words go in this box.

    When to use it: Say this when a form box is not clear.

    I'm is one piece and means I am.

    Say it: Stress is on sure.

  2. A staff member points to the blank line where Ana should write her name.

    Sign here.

    Write your name on this line.

    When to use it: You tell someone where to write their name.

    This is a short instruction, not a question.

  3. Ana holds out her insurance card toward the staff member at the counter.

    Here's my insurance card.

    You give them the card from your health plan.

    When to use it: Hand over your health card at a clinic desk.

    Here's is one piece and means here is.

    Say it: Here's and my can link.

  4. Ana listens as the staff member asks about the date of her birth.

    What's your date of birth?

    They ask the month, day, and year you were born.

    When to use it: Ask the month, day, and year someone was born.

    In the US, write month, then day, then year.

    Say it: Of is often a short, weak sound.

  5. Ana turns the clipboard toward the staff member and points to the blank name line.

    Do I need to sign this?

    Ask if you must write your name on the form.

    When to use it: Ask this before you write your name on a form.

    Need to means it is necessary.

  6. The staff member tries Ana’s insurance card on the reader while Ana watches.

    It won't scan.

    The machine cannot read the card.

    When to use it: Say this when a machine cannot read a card.

    Won't is one piece and means will not.

    Say it: Won't has a long o, not like want.

Story — the card will not scan

Watch Ana at the clinic desk. She does not know what to write on the form.

The highlighted words are the lines you just learned.

  1. Pale clinic walls. Ana stands at the front desk with a clipboard.
  2. StaffHave a seat.please sit down
  3. Ana sits and stares at an empty box.
  4. AnaExcuse me. I'm not sure what to write here.She wants attention, and she does not know the words for the box.
  5. StaffWhat's your date of birth?They ask the month, day, and year you were born.
  6. AnaYou want the whole story of the day I was born?She thinks she must tell the whole birth story.
  7. StaffMonth, day, then year.Write the month first, then the day, then the year.
  8. AnaMay 14, 1998.She says the month, day, and year she was born.
  9. StaffSign here.Write your name on this line.
  10. AnaDo I need to sign this?Ask if you must write your name on the form.
  11. StaffYes. Sign here, please.She says yes and points to the line again.
  12. AnaHere's my insurance card.You give them the card from your health plan.
  13. StaffI'll scan it.She will use the machine on the card.
  14. AnaIt won't scan.The machine cannot read the card.
  15. StaffThat's okay. I'll type it in.The problem is small. She will type the numbers.

Practice — boxes and signatures

Ten quick exercises wait here. You will listen, pick, match, fill a gap, and build a line.

They stay short, so the round moves fast.

0 of 10 done

  1. What did you hear?

  2. Match the pairs

    English

    Sign here.Drop the Simple English here
    Here's my insurance card.Drop the Simple English here
    What's your date of birth?Drop the Simple English here
    It won't scan.Drop the Simple English here

    Simple English

    Drag a Simple English line onto its English, or tap one and then the other.

  3. What do you say?

    You are at the clinic desk. You take out the card from your health plan.

  4. What does it mean?

    It won't scan.

  5. Fill the gap

    Write your name on this line.

    ____ here.

  6. Build the line

    They ask the month, day, and year you were born.

    ?

    Tap the words in order.

  7. Pick the reply

    Staff says:

    Sign here.

    Write your name on this line.

    And you reply with:

  8. Swap the word

    The machine at the desk beeps. Tell the staff the problem.

    It ____ scan.

  9. True or false?

    This line asks someone to stand up.

  10. What do you say?

    The staff member is looking at the computer. You need her to look at you.

Say it — say it at the desk

Now you're Ana at the clinic desk. When it's your turn, tap the microphone and speak the line.

Tap play first if you want to hear the line. Your recording stays on your device.

  1. StaffHave a seat.please sit down
  2. Ana (you)The first box on the form is empty.

    I'm not sure what to write here.

    You do not know which words go in this box.

0 of 4 said

Recap — what you can say now

EnglishSimple English
I'm not sure what to write here.You do not know which words go in this box.
Sign here.Write your name on this line.
Here's my insurance card.You give them the card from your health plan.
What's your date of birth?They ask the month, day, and year you were born.
Do I need to sign this?Ask if you must write your name on the form.
It won't scan.The machine cannot read the card.
Next: lesson 111Making an appointment

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A quick round with the Yak Cards each day keeps these form lines ready for the clinic.

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