Get Tia Clinic Intake Form - The Neuroscience Center At Nna

Filling out the Tia Clinic intake form is an essential step in ensuring you receive the appropriate care at The Neuroscience Center at NNA. This guide provides detailed, step-by-step instructions on how to complete the form accurately and efficiently.

Follow the steps to accurately fill out the form.

1. Press the ‘Get Form’ button to access the Tia Clinic intake form and open it for completion.
2. Begin with the date field at the top of the form, entering the current date to help track your submission.
3. Fill in your name and phone number in the designated sections labeled 'Patient name' and 'Patient phone'.
4. Enter your weight in the specified field to provide important health information.
5. Indicate your primary insurance provider in the 'Primary insurance' section and provide the corresponding phone number.
6. State your age in the appropriate section to assist with your clinical assessment.
7. Upload a copy of the patient's insurance card as requested on the form to ensure all necessary billing information is available.
8. Complete the section for your Primary Care Physician (PCP) by entering their name and phone number.
9. Specify how you were referred to this clinic by selecting an option from the dropdown: PCP office, ER, NNA doc, or other.
10. If applicable, fill in the name of the person who is calling for the appointment in the 'Caller name' field.
11. Answer the questions regarding known risk factors by checking the relevant boxes that apply to your medical history, such as previous CVA/TIA, diabetes, and hypertension.
12. Indicate any medications the patient is currently taking by checking the appropriate boxes for ASA, , , or .
13. Respond to the symptom assessment question about recent symptoms experienced by the patient within the past week, marking any symptoms that currently apply.
14. Answer the questions asking when the symptoms began, how long they lasted, and whether they are still present.
15. Complete the MRI compatibility section by checking any relevant limitations or previous issues with MRI procedures.
16. After all fields are completed, review your entries for accuracy, then save changes, download, print, or share the form as needed.

Complete your Tia Clinic intake form online today to ensure your care is timely and effective.