Get the free New Patient Form - Dan Pillow, Ph.D., PC

Dan Pillow, Ph.D. P.C. Licensed Psychologists 200 Diversion, Suite 150 Tel 2482994315 Rochester Hills, Michigan 48083 Fax 2484134059 New Patient Information Sheet Date of Appointment: Last Name: Middle

How to fill out new patient form

How to fill out a new patient form:

1. Start by carefully reading through the entire form to ensure you understand the information being requested.
2. Begin by providing your full name, including any middle name or initial.
3. Enter your date of birth accurately to ensure proper identification.
4. Provide your current address, including street, city, state, and zip code.
5. Fill in your contact information, including your primary phone number and email address.
6. Indicate your gender by selecting the appropriate option provided.
7. Enter your social security number, if required. This is often used for insurance and billing purposes.
8. Provide your emergency contact details, including the person's name, relationship to you, and their phone number.
9. If you have any known allergies or medical conditions, make sure to accurately list them.
10. Review and sign any consent forms included in the new patient form.
11. If you have health insurance, provide the necessary information such as your insurance company, policy number, and group number.
12. Lastly, don't forget to date the form and provide any additional information requested.

Who needs a new patient form?

1. New patients visiting a healthcare provider for the first time typically need to fill out a new patient form.
2. Individuals who have not visited a specific healthcare facility within a certain time frame may also be required to complete a new patient form.
3. Patients seeking care from a different healthcare provider or practice may also need to fill out a new patient form, as their previous medical records may not be readily accessible.

Note: The specific requirements for filling out a new patient form may vary depending on the healthcare provider or facility. Always follow the instructions provided by the healthcare provider to ensure accurate completion of the form.

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