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New Patient Information Form **Please use BLUE or BLACK Ink** The Physical Therapy Clinic, Inc. DBA Axis Physical Therapy 26 Office Park Dr. Jacksonville, NC 28546 Welcome to our Practice! Please

How to fill out new patient information form

How to fill out a new patient information form:

1. Start by gathering all the necessary information. You will need personal details such as your full name, date of birth, gender, and contact information including your address, phone number, and email.
2. Next, provide your medical history. This includes any past and current medical conditions, allergies, medications you are currently taking, and any surgeries or hospitalizations you have had. Be as specific as possible to ensure accurate and comprehensive medical care.
3. Fill in your insurance information. If you have insurance, include details of your policy such as the insurance company's name, policy number, and group number. Additionally, provide any necessary contact information for your insurance provider. This will help streamline the billing process and ensure proper coverage.
4. Include emergency contact information. Provide the name, relationship, and contact details for at least one person who can be reached in case of an emergency. This should be someone who is easily reachable and knowledgeable about your medical history.
5. If applicable, complete a consent form. This form grants the healthcare provider permission to treat you and access your medical records. Read through it carefully to ensure you understand the terms and conditions outlined.
6. Lastly, sign and date the form. This serves as confirmation that the information you have provided is accurate and complete. If there are any sections or questions that you are unsure about, do not hesitate to ask a staff member for clarification.

Who needs a new patient information form:

1. Any individual who is seeking medical care at a new healthcare facility or with a new healthcare provider will need to fill out a new patient information form. This form allows healthcare professionals to gather essential information about the patient's medical history, allergies, and insurance coverage.
2. Patients who have not previously visited a particular medical practice or hospital will typically be required to complete a new patient information form. This ensures that the healthcare providers have the necessary information to provide appropriate care and make informed treatment decisions.
3. Even if you have visited the same healthcare provider or facility in the past, you may still be required to update your information periodically. This helps ensure that the medical records are accurate, and any changes in your health or contact information are taken into account.

In summary, filling out a new patient information form involves providing personal details, medical history, insurance information, and emergency contact information. It is a necessary step for anyone seeking medical care at a new healthcare facility or with a new healthcare provider.

For pdfFiller’s FAQs

What is new patient information form?

New patient information form is a document that collects necessary information about a patient who is visiting a healthcare provider for the first time.

Who is required to file new patient information form?

New patients visiting a healthcare provider are required to fill out the new patient information form.

How to fill out new patient information form?

Patients can fill out the new patient information form by providing accurate and detailed information about their medical history, contact information, insurance details, and any other relevant data.

What is the purpose of new patient information form?

The purpose of the new patient information form is to gather essential details about the patient that will help healthcare providers in providing appropriate care and treatment.

What information must be reported on new patient information form?

Information such as personal details, medical history, current medications, allergies, insurance information, emergency contact, and any specific health concerns should be reported on the new patient information form.

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