Get Concentra Patient Information

Filling out the Concentra Patient Information online form is an important step in ensuring your visit goes smoothly. This guide will provide you with clear, step-by-step instructions to assist you in completing each section of the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information. Fill in your last name, first name, social security number, and date of birth in the specified fields. Ensure that your date of birth follows the MM/DD/YYYY format.
3. Provide your driver's license number and the state in which it was issued. Select the appropriate license classification if applicable.
4. Fill in your residential address, including city, state (abbreviated), and ZIP code. Include your contact phone number (home or cell) and a work phone number if applicable.
5. Enter your email address and occupation. If you have a hire date with your employer, include that information here.
6. In the Employer section, input the name and location or store number of your employer, along with the address, city, and information about your supervisor, including their name and phone number.
7. Indicate whether your employment is arranged through a temporary hire agency by checking 'Yes' or 'No.' If 'Yes', provide the agency name and phone number.
8. In the 'Reason for Today's Visit' section, select the main reason for your visit by checking the appropriate box for work-related injury or non-injury services.
9. If you are here for a work-related injury, complete the fields regarding the injury date, time, and location. Briefly describe how the injury occurred and specify the part of your body that is injured.
10. Check the appropriate box to indicate which side of your body is injured, and use the figure provided to circle the injured areas.
11. At the bottom of the form, verify that the information you have provided is correct. Sign and date the form to confirm that the details are accurate.
12. If applicable, indicate that you have received Concentra’s Notice of Privacy Practices by printing your name, signing, and providing the date and time that you received it.
13. Lastly, complete the 'For office use only' section by providing the sign-in date and time as required.
14. Once all sections are completed, proceed to save your changes. You can download, print, or share the form as necessary.

Start filling out your Concentra Patient Information form online now!