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425.747.4477 schurorthodontics.com 14645 Belted Rd, Ste E101 Bellevue, WA 98007 Confidential Patient Information Form Adult Patient Information Name: Title Last First Middle Suffix Preferred Name
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How to fill out confidential patient information form:
01
Start by writing your full legal name in the designated space.
02
Provide your date of birth, gender, and contact information (phone number, address, and email).
03
Clearly state your current health insurance information, including the policyholder's name, policy number, and insurance company.
04
Indicate any known allergies or medical conditions that may be relevant.
05
Fill in the emergency contact information, including the name, relationship, and contact details of a person to be notified in case of an emergency.
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Include your primary care physician's name and contact information.
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If applicable, provide any additional healthcare providers involved in your care, along with their contact information.
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Carefully review the form for accuracy and completeness before signing and dating it.
Who needs confidential patient information form:
01
Patients visiting healthcare facilities or providers for the first time.
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Individuals seeking medical care and treatment at clinics, hospitals, or private practices.
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Patients undergoing medical procedures, examinations, or consultations that require their personal and medical information for proper diagnosis and treatment.
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