Get the free Dr Harnsberger Patient Intake Form 3 pages-0.doc - patients dartmouth-hitchcock

Department of General Surgery Name: DOB: PATIENT INTAKE FORM Date: Reason for your visit today: Please list past surgeries, if any: Surgery Date Doctor Hospital Please list any medical problems (examples:

How to fill out dr harnsberger patient intake

How to Fill Out Dr. Harnsberger Patient Intake:

1. Begin by carefully reading through the patient intake form provided by Dr. Harnsberger's office. This will ensure that you are familiar with the information being requested and can gather any necessary documents or details beforehand.
2. Gather all relevant personal information, such as your full name, date of birth, and contact details. Make sure to accurately provide your current address, phone number, and email address so that Dr. Harnsberger's office can easily reach out to you if necessary.
3. Fill in any medical history details requested on the form. This may include previous medical conditions, surgeries, allergies, or any ongoing medications. Provide as much information as possible, ensuring accuracy and clarity.
4. Indicate your emergency contact details. In case of any unforeseen medical emergencies, it is essential to provide the name, contact number, and relationship of a person who can be reached quickly.
5. If you have health insurance, provide your insurance information, including the policy number and group number. This step is crucial for accurate billing and to ensure that you receive the appropriate coverage for any medical treatments or services.
6. If you are undergoing treatment with other healthcare providers, provide their names and contact details. This allows Dr. Harnsberger's office to coordinate your care and collaborate with other medical professionals if necessary.
7. Sign and date the patient intake form. By doing so, you acknowledge that all the information provided is true and accurate to the best of your knowledge.

Who needs Dr. Harnsberger Patient Intake:

1. New patients visiting Dr. Harnsberger's office for the first time are required to fill out the patient intake form. This allows the doctor to obtain a comprehensive understanding of the patient's medical history and current health status, enabling them to provide appropriate care and treatment.
2. Existing patients who have previously filled out the patient intake form may also be required to update their information periodically. This ensures that the doctor has the most up-to-date details and can make informed decisions regarding the patient's healthcare.
3. Patients who are transferring from another healthcare provider to Dr. Harnsberger's practice will also need to complete the patient intake form. This assists in the smooth transition of medical records and ensures continuity of care.

In summary, filling out the Dr. Harnsberger patient intake involves providing accurate personal and medical information, emergency contact details, insurance information, and any relevant healthcare provider details. It is essential for both new and existing patients to complete this form to ensure proper healthcare management.

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