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Name and Clinic NumberApproval Date:
Not to be used after:September 7, 2018,
March 13, 2019RESEARCH PARTICIPANT CONSENT AND PRIVACY
AUTHORIZATION FORM
Study Title: OBERTO101, A Phase 1, Multiple dose,
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How to fill out name and clinic number
How to fill out name and clinic number
01
To fill out the name and clinic number, follow these steps:
02
Locate the designated fields for name and clinic number on the form.
03
Begin by entering your full name in the name field, ensuring that you spell it correctly.
04
Next, locate your clinic number and enter it accurately in the designated field.
05
Double-check the information you entered to ensure accuracy.
06
Once you have filled out the name and clinic number, proceed to the next section of the form.
Who needs name and clinic number?
01
Anyone who is required to provide personal and medical information at a clinic or healthcare facility needs to provide their name and clinic number.
02
This information is often required for identification, billing, appointment scheduling, and medical record purposes.
03
Patients, visitors, and individuals seeking medical services are typically asked to provide their name and clinic number.
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What is name and clinic number?
Name and clinic number refer to the personal information and identification number of an individual seeking medical services at a healthcare facility.
Who is required to file name and clinic number?
Healthcare providers and facilities are required to collect and file name and clinic number for each patient.
How to fill out name and clinic number?
Name and clinic number can be filled out on the patient's registration form or electronic health record system at the time of their visit.
What is the purpose of name and clinic number?
The purpose of name and clinic number is to accurately identify and track patients within the healthcare system for effective treatment and record-keeping.
What information must be reported on name and clinic number?
The name and clinic number must include the patient's full name and unique clinic identification number assigned by the healthcare facility.
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