Get Hospital Intake Form

Completing the Hospital Intake Form online is an essential step in ensuring proper patient care. This guide provides clear and detailed instructions to help users fill out the form accurately and efficiently.

Follow the steps to complete the Hospital Intake Form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred browser.
2. Begin by entering today's date in the specified format at the top of the form. This includes the day, month, and year sections.
3. Fill out the patient information section. Provide the patient's name, date of birth, age, and gender. Indicate citizenship in the appropriate field.
4. Complete the permanent residence information by including the patient's address, home phone number, and any additional contact number.
5. Indicate the family's preferred spoken language and whether an interpreter is needed during medical visits.
6. Fill in details regarding spiritual affiliation and ethnicity, as well as any special needs that the patient has, to ensure appropriate accommodations.
7. In the parent information sections, provide the necessary details for both parents, including their names, dates of birth, contact information, and employer details.
8. Provide referring physician information, including the name and whether this physician is the child's primary care physician.
9. Fill out payment information by indicating the method of payment (e.g., wire transfer, credit card) and complete insurance details, attaching copies of insurance cards as required.
10. Provide additional medical information regarding the patient’s current diagnosis or health issues, feeding methods, and any other relevant medical needs.
11. Complete the acceptance checklist ensuring all required documents are included and marked appropriately.
12. Once all sections are filled out, review the form for accuracy. You can save changes, download, print, or share the form as needed.

Complete your Hospital Intake Form online today for a smooth admission process.