Get the free New Patient Information - Mt Sterling Clinic PLLC

New Patient Information Date: PLEASE PRINT LEGIBLY Name: First Middle Last Social Security Number: Date of Birth Age Home Phone Work Phone Cell Phone Street Address: City: State: Zip Code: Email address:

How to fill out new patient information

How to fill out new patient information:

1. Start by writing your full name in the designated space. Include your first, middle, and last names.
2. Next, provide your date of birth. This helps healthcare professionals accurately identify and track your medical records.
3. Provide your contact information, including your phone number, address, and email address. This ensures that the healthcare facility can reach out to you for any necessary communication.
4. If applicable, indicate your preferred method of contact. Some patients may prefer to be contacted via phone, while others may prefer email or text message.
5. Specify your gender. This information helps medical professionals consider any gender-specific healthcare needs.
6. Include your emergency contact details. Provide the name, phone number, and relationship of a person who can be contacted in case of emergency.
7. Indicate your medical history. This includes any past illnesses, surgeries, or chronic conditions. It is important to be thorough and honest to ensure accurate and effective healthcare.
8. Provide information about your current medications. Include the name, dosage, and frequency of any prescribed or over-the-counter drugs you are taking.
9. If you have any known allergies or sensitivities, make sure to mention them. This information helps healthcare professionals prevent any adverse reactions during treatment.
10. Finally, sign and date the form to certify that the provided information is accurate and complete.

Who needs new patient information?

1. New patients seeking healthcare services from a medical facility.
2. Healthcare providers and staff who require accurate and up-to-date patient information for effective treatment and care.
3. Insurance companies that need patient information for claims processing and coverage verification.

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