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707 S. Garfield Ave., Suite B002 Alhambra, CA 91801 Tel: 6262272777 Fax: 6262272747 www.makoncology.com NEW PATIENT QUESTIONNAIRE Patient Name: Date: Welcome to Our Radiation Oncology Center! We hope
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How to fill out new patient form
Steps to fill out a new patient form:
01
Start by obtaining the form: Visit the reception desk of the healthcare facility or download the form from their website.
02
Read the form instructions: Take a moment to carefully read the instructions provided on the form. This will help you understand what information is required and how to fill it out correctly.
03
Personal information: Begin by entering your personal details such as your full name, date of birth, address, and contact information.
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Medical history: The form may ask you to provide details about your medical history. This can include any pre-existing conditions, allergies, medications you are currently taking, and previous surgeries. Be as thorough as possible to ensure accurate medical care.
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Insurance information: If you have health insurance, you will likely need to provide your insurance details, including your policy number and any relevant identification numbers.
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Emergency contact information: Fill in the spaces provided for emergency contact details. This information will be used in case of any medical emergencies or important communication needs.
07
Consent and signatures: Read any consent statements carefully and sign where necessary to acknowledge your understanding and agreement. This may include consent for treatment, release of medical information, or financial responsibility.
08
Review and double-check: Before submitting the form, review all the information you have provided. Make sure there are no errors or omissions.
09
Submitting the form: Return the completed form to the healthcare facility by either handing it in at the reception desk or following any instructions provided on the form or the facility's website.
Who needs a new patient form?
Anyone who is visiting a healthcare facility for the first time or has not visited in a long time may need to fill out a new patient form. This form is essential for healthcare providers to gather necessary information about a patient's medical history, personal details, and insurance information. By filling out this form, healthcare professionals can provide personalized and appropriate care, ensuring a smooth and efficient treatment process.
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A new patient form is a document used to collect information from individuals who are seeing a healthcare provider for the first time.
Who is required to file new patient form?
New patients who are seeking medical treatment from a healthcare provider are required to fill out a new patient form.
How to fill out new patient form?
Patients can fill out a new patient form by providing accurate and complete information about their medical history, current medications, allergies, and contact details.
What is the purpose of new patient form?
The purpose of a new patient form is to gather important information about the patient's health in order to provide them with the best possible care.
What information must be reported on new patient form?
Information such as medical history, current medications, allergies, contact details, insurance information, and emergency contacts must be reported on a new patient form.
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