Get Patient Registration Form - Quality Sleep Solutions

Completing the Patient Registration Form online is an essential step to ensure you receive the appropriate care for your sleep needs. This guide will provide clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete your Patient Registration Form.

1. Press the ‘Get Form’ button to obtain the Patient Registration Form and open it in your preferred editing tool.
2. Begin by entering your personal details in the 'Patient Name', 'SSN', 'Address', 'Email', 'City', 'State', 'Home Phone', 'Age', and 'Zip Code' fields. Ensure that all information is accurate and up to date.
3. Fill out the 'Work Phone' and 'Cell Phone' sections. Providing multiple ways to contact you helps us reach you more effectively.
4. Navigate to the demographic information section and input your 'Date of Birth', 'Sex', 'Height', 'Weight', and 'Race/Ethnicity' (optional). This information assists in tailoring your care.
5. Complete the 'Sleep Center Facility' section by indicating the facility you are associated with and your 'Marital Status'. You may also enter your 'Spouse Name' if applicable.
6. Input your educational background by selecting the 'Highest level of education completed' and specify your 'Primary Language'. This information aids in providing effective communication.
7. In the 'Referring Physician Name' section, fill in the name of your referring doctor and their phone number. If you have a different primary care physician, include their details as well.
8. Proceed to the 'Next of Kin/Emergency Contact' section and provide the name, relationship, address, and phone numbers for your emergency contact.
9. Fill out the 'Employment Information' section by indicating your 'Employment Status', 'Name of Employer', and their contact information.
10. Complete your 'Insurance Information', including the name of the insured, relationship to patient, insurance provider, and relevant policy details.
11. Answer the questions regarding your sleep medicine history diligently, marking any symptoms or concerns. This section is crucial for understanding your sleep patterns.
12. Review all sections for completeness and accuracy. Your responses should reflect your health and history honestly.
13. Finally, save your changes, and you may choose to download, print, or share the form as needed to ensure it is provided to the appropriate facility.

Start your journey to better sleep by completing the Patient Registration Form online today!