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VRI Samaritan Women's Center 2581 Samaritan Drive, Suite 206 San Jose, CA 95124 Phone: (408) 3586881 Fax: (408) 3568785 PATIENT INFORMATION FORM Last Name: First Name: Middle Name: MAN: DOB: Gender:

How to fill out vri samaritan form

How to fill out VRI Samaritan:

1. Begin by gathering all the necessary information, such as personal details, medical history, and contact information.
2. Start with the basic sections, like filling out your name, address, and phone number in the appropriate fields.
3. Provide accurate information about your medical history, including any pre-existing conditions, allergies, or medications you are currently taking.
4. Indicate whether you have any emergency contacts and provide their names, phone numbers, and relationships to you.
5. Fill out any additional sections or checkboxes related to your specific needs or preferences, such as dietary restrictions or mobility assistance requirements.
6. Review all the information you have filled out to ensure its accuracy and completeness.
7. If there are any sections or questions that you are unsure about or need clarification on, don't hesitate to seek assistance from the relevant party or contact VRI Samaritan directly.

Who needs VRI Samaritan:

1. Individuals with chronic illnesses or medical conditions that may require emergency medical attention.
2. Elderly individuals living alone or in assisted living facilities who may require immediate assistance in case of a medical emergency.
3. People with disabilities who may need help in accessing medical services or communicating with healthcare professionals during emergencies.

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What is vri samaritan?

VRI Samaritan is a form used to report information about individuals who have voluntarily self-identified as being at risk of suicide and in need of support.

Who is required to file vri samaritan?

VRI Samaritan must be filled out by healthcare providers or organizations who have identified individuals at risk of suicide.

How to fill out vri samaritan?

VRI Samaritan can be filled out by providing information about the individual at risk, including their name, contact information, risk factors, and any support services being provided.

What is the purpose of vri samaritan?

The purpose of VRI Samaritan is to ensure that individuals at risk of suicide receive the necessary support and intervention to prevent self-harm.

What information must be reported on vri samaritan?

Information such as the individual's name, contact information, risk factors, support services being offered, and any previous suicidal attempts must be reported on VRI Samaritan.