Get Sample - Interior Health Authority

Filling out the SAMPLE - Interior Health Authority form online is a straightforward process that ensures all necessary information is collected prior to your admission. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your form online.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Enter your legal name in the designated field, including your last name, first name, and middle name.
3. If applicable, provide any previous surnames or maiden names in the specified section.
4. Indicate your gender by selecting the appropriate checkbox for either 'Female' or 'Male'.
5. Fill in your personal health care number, commonly referred to as your Care Card number.
6. Input your complete mailing address, ensuring to include your city, province, and postal code.
7. If your street address differs from your mailing address, fill out the complete street address in the provided field.
8. Record your date of birth in the format of day/month/year.
9. If you have lived at your current address for less than six months, include your previous address.
10. Provide your home phone number and, if applicable, an alternate phone number.
11. Input the next of kin's name, including last name and first name, in the designated section.
12. Enter the name of your family doctor as required.
13. Fill in the alternate phone number for your next of kin.
14. Provide the phone number for your next of kin.
15. Indicate the relationship of the next of kin to you.
16. If applicable, enter the maternity date in the specified format.
17. If there is a surgeon involved, please provide their name.
18. Enter the surgery date, if applicable, in the day/month/year format.
19. Select an accommodation request by checking the appropriate box: Ward, Private, or Semi-Private.
20. Be aware that the patient is responsible for the charges related to private and semi-private rooms.
21. If you have extended health care, provide the insurance company name, group number, ID number, member's name, and relationship to the patient.
22. Sign and date the form in the designated fields, using the day/month/year format.
23. After completing all sections, review the information for accuracy before proceeding to save changes, download, or print the form.

Complete your form online today to ensure a smooth admission process.