Get Pre-admission Questionnaire - Kaleida Health

The Pre-admission Questionnaire is an essential document for patients preparing for their admission to Kaleida Health. Completing this form accurately helps ensure a smooth admission process by collecting necessary information about the patient and their healthcare needs.

Follow the steps to complete the Pre-admission Questionnaire online effectively.

1. Press the ‘Get Form’ button to obtain the Pre-admission Questionnaire and open it for editing.
2. Begin by clearly printing all information in the appropriate fields, starting with the reason for admission and your scheduled admission date, along with the admitting physician's name.
3. Enter the patient’s full name (last, first, middle) along with their social security number in the designated sections.
4. Fill in the address by providing the street name, number, city, state, and zip code, ensuring the information is accurate.
5. Include the patient’s phone number and an emergency phone number for immediate contact.
6. List the patient’s place of birth by entering the city.
7. Complete the sections related to the parents, including their names, addresses, and phone numbers, ensuring to specify which parent is applicable.
8. Indicate whether the patient has medical and dental insurance, providing the address of the insurance plan, subscriber details, and any relevant identification numbers.
9. Next, describe the relationship to the patient and note who carries the insurance, along with their city and address if it differs from the patient’s.
10. If the parents are divorced or separated, clearly indicate financial responsibility and custody arrangements.
11. Document the patient's sex, race, religion, and any prior last name, making sure information is filled in as applicable.
12. If the patient has any prior medical issues or special considerations, please include comments in the provided section.
13. Once all fields are completed, review the document for accuracy, then save any changes made.
14. Finally, you may download, print, or share the completed form as required.

Start filling out the Pre-admission Questionnaire online today to ensure a seamless admission process.