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FLU CONSENT FORM FOR OFFICE USE ONLY New Patient? qYesqNoInsurance Verification #:Patient Last Name: Gender: qMStaffFirst Name: DOB:FAGE:Mailing Address:Daytime Phone:City:Primary Care Physician:State:Ethnicity:Zip:Preferred
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To fill out for office use only, follow these steps:
1. Obtain the form labeled 'For Office Use Only'.
02
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03
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04
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05
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06
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Who needs for office use only?
01
Anyone who has specific information or documentation that is meant for internal office use only may need to fill out a form designated for office use only.
02
This could include employees, administrators, or individuals who need to provide confidential or restricted information that should not be disclosed to the public or outside the office.
03
By filling out a form labeled 'For Office Use Only', the person ensures that the information remains confidential and is used only for internal purposes.
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