Get the free PATIENT REGISTRATION FORM Westside Gastrointestinal - westsidegi

PATIENT REGISTRATION FORM Westside Gastrointestinal Specialists, LLC Jeffrey R. Christ, M.D. & Juan Benitez, M.D. Today's Date: Please print all information in the spaces provided. Be sure to complete

How to fill out patient registration form westside

How to fill out the patient registration form at Westside:

1. Start by writing your full name in the designated space on the form. Make sure to use your legal name as it appears on your identification documents.
2. Fill out your date of birth, including the month, day, and year. This information is important for verifying your identity and ensuring you receive appropriate medical care.
3. Provide your contact information, including your address, phone number, and email address. This will allow the clinic to reach out to you for any necessary follow-up or future appointments.
4. Indicate your gender by checking the appropriate box. This information helps the medical professionals understand your specific healthcare needs.
5. Include your emergency contact information. Provide the name, relationship, and phone number of someone who should be contacted in case of an emergency during your visit.
6. Note any allergies or medical conditions you have. This information is crucial for the medical staff to be aware of so they can provide appropriate care and avoid any potential complications.
7. Include your insurance information if applicable. This includes the name of your insurance provider, policy number, and any necessary group ID numbers. Make sure to bring your insurance card to your appointment as well.
8. Read through and sign any necessary consent forms, acknowledging that you understand the clinic's policies and procedures, as well as your rights as a patient.

Who needs the patient registration form at Westside?

1. New Patients: Any individual who is visiting the Westside clinic for the first time will need to fill out the patient registration form. This allows the clinic to gather necessary information and establish your medical record.
2. Existing Patients: Even if you have been to the Westside clinic before, you may still need to fill out a new patient registration form if there have been any changes to your personal information, insurance, or medical history. This helps the clinic maintain accurate and up-to-date records for each patient.
3. Minors: If you are under the age of 18, a parent or guardian will need to fill out the patient registration form on your behalf. They will provide their information as well as the necessary information about the minor patient.

Note: It is recommended to arrive early for your appointment to allow enough time to fill out the patient registration form completely and accurately. This will help ensure a smooth check-in process and minimize any delays.

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