Get Patient Demographic Information - Desert Spine Surgeons

Filling out the Patient Demographic Information form is an important step in ensuring accurate medical care and communication with Desert Spine Surgeons. This guide provides clear instructions on how to complete each section of the form online, making the process straightforward and user-friendly.

Follow the steps to accurately complete your form.

1. Press the 'Get Form' button to access the Patient Demographic Information form and open it in your document management tool.
2. Begin by entering the patient’s name in the designated field, followed by their date of birth. This information is crucial for identifying the patient in the system.
3. Complete the address section by filling in the street, city, state, and zip code fields. This allows for accurate correspondence and service provision.
4. Provide the relevant phone numbers: home, work, and cell. Including multiple contact options ensures that you can be reached promptly if necessary.
5. Enter the email address to receive electronic communications. This is vital for appointment confirmations and other important notices.
6. Fill out the pharmacy section with the pharmacy name, address, and phone number, which facilitates prescription management.
7. Indicate the patient’s sex and race in the provided fields, as this demographic information may be required for health records.
8. Complete the social security number, ethnicity, preferred language, and marital status sections. Marital status may help in understanding the patient’s support system.
9. If applicable, provide the spouse’s name, referring physician, and primary care physician's information, as this helps in coordinating care.
10. Indicate how you first heard about Desert Spine Surgeons. This information is useful for understanding patient outreach.
11. If the responsible party differs from the patient, fill out their information, including name, relationship to the patient, address, and phone number.
12. In case of emergency, provide the name, relationship, and contact numbers for your emergency contact.
13. Fill in the primary and secondary insurance information, including policy numbers and employer details. Completing this section accurately is essential for insurance billing.
14. Read and consent to the authorization statement. Signature and date are required to finalize your form.
15. Once all information is entered and reviewed for accuracy, you can choose to save the changes, download, print, or share the form as needed.

Start completing your Patient Demographic Information form online today for efficient and effective healthcare!