Get Registration Packet - Rachel Dultz

Completing the Registration Packet for Rachel Dultz, MD, FACS, is essential for a smooth and efficient visit to the practice. This guide provides clear instructions for each section of the form to ensure that you can easily fill it out online and bring the necessary information to your appointment.

Follow the steps to complete your Registration Packet online.

1. Click ‘Get Form’ button to access the Registration Packet and open it in your preferred online document editor.
2. Fill out the patient information section with your details including your name, contact information, and marital status. Ensure that your information is current and accurate.
3. Provide your insurance information, including the name of the insurance company, policy numbers, and the responsible party for the bill. Confirm if you have secondary insurance, if applicable.
4. In the emergency contact section, list a local friend or relative, along with their relationship to you and their contact numbers.
5. Complete the Breast Information Sheet by providing your family history of breast cancer, personal breast health details, and reasons for your visit.
6. In the Medical History Form, record your chief complaint, past medical history, and any allergies or medications you are taking. Be thorough to ensure accurate health records.
7. Review the Patient Authorization Form, where you will authorize the release of your protected health information to designated individuals.
8. Finish by signing and dating the forms where required. Once completed, you can save the changes, download a copy, print it out, or share it as needed.

Complete your Registration Packet online today to ensure a seamless visit to Rachel Dultz, MD, FACS.