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1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Fill in your personal information including your name, social security number, and date of birth.
3. Provide your current address, city, state, and zip code along with your home, cell, and work phone numbers.
4. Enter your email address, pharmacy address, and phone number.
5. Complete the employer section by inputting your employer's name and address.
6. If applicable, fill out the spouse information by providing their name, social security number, date of birth, and employer details.
7. In case of emergency, provide the name and contact information of your emergency contact.
8. Indicate who referred you to Dr. Fong by filling in the appropriate field.
9. Complete the insurance information section and ensure that you make note of any agreements regarding payment at the time of service.
10. Read and check all necessary authorizations regarding the release of information and assignment of benefits.
11. Sign and date the form, confirming the accuracy of the information you have provided.
12. After completing all the sections, you can save your changes, download the form, print it, or share it as needed.

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