Get the free Initial Intake Form - Pediatric Boulevard
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Pediatric Boulevard, LLC Physical: 2814 Gray Fox Road, Indian Trail, NC 28079 Correspondence: 2814 Gray Fox Road, Monroe, NC 28110 Business: 7048210568 Fax: 7048210570 Email: info pediatricboulevard.com
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How to fill out initial intake form
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01
Read the instructions: Carefully read the instructions or guidelines provided on the form to understand the specific information required and how to fill it out correctly.
02
Personal information: Start by providing your personal information such as your full name, contact details, address, and date of birth. It is important to ensure accuracy and legibility when filling out this section.
03
Medical history: Fill out the medical history section by providing details of any pre-existing medical conditions, allergies, medications, and previous surgeries or treatments. Be honest and provide as much information as possible to help healthcare professionals assess your health accurately.
04
Insurance information: If applicable, provide your insurance information including policy number and contact details for verification purposes. This section may also require you to authorize the release of information to your insurance company.
05
Emergency contact: Include the contact information of a trusted person who can be reached in case of any emergencies. Make sure to provide their full name, relationship to you, and contact number.
06
Signature and date: Review your form for any missing information or mistakes. Once you are satisfied, sign and date the form to acknowledge that all the information provided is accurate to the best of your knowledge.
Who needs the initial intake form?
The initial intake form is typically required by various healthcare facilities such as hospitals, clinics, or doctors' offices. It is necessary for new patients as it helps healthcare professionals gather vital information about the patient's medical history, insurance details, and emergency contacts. This form ensures that healthcare providers have all the necessary information for proper diagnosis, treatment, and communication with the patient and their insurance providers.
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