Get Patient Information Form

Filling out the Patient Information Form online is a straightforward process that helps ensure your healthcare provider has accurate and up-to-date information. This guide will assist you in completing each section of the form with ease and confidence.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter today’s date in the designated field.
3. Provide your full name, including first name, middle initial, and last name, as well as your preferred nickname if applicable.
4. Fill in your address, including street address, city, state, and zip code.
5. List your contact phone numbers—home, work, and mobile—as well as your email address. By entering your email, you agree to receive communications from your provider.
6. Indicate your preferred method of contact by checking the relevant boxes for home phone, work phone, mobile phone, or email for appointment reminders.
7. Enter your Social Security number, date of birth, and driver's license number, including the state of issuance.
8. Provide information about your employment, including your employer’s name, occupation, and contact information.
9. Indicate your sex and marital status by selecting the appropriate options.
10. In the case of an emergency, list a contact person along with their relationship to you.
11. If you are a minor, provide the name of the responsible party and their relationship to you, along with their contact details.
12. Fill in your dental benefit plan information, including primary and secondary plans, names of insured parties, policy numbers, and relationships to the insured.
13. Complete the medical plan information as required.
14. Indicate who referred you to the practice and list any immediate family members who are also patients.
15. Review the patient responsibilities section and initial where indicated to confirm your understanding and acceptance.
16. Sign and date the form to authorize the release of your information and confirm all details are accurate.
17. After filling out the form, save any changes, and choose whether to download, print, or share the completed form as needed.

Start completing your Patient Information Form online today for a smoother healthcare experience.