Follow the steps to complete your enrollment form with ease.

1. Click the ‘Get Form’ button to acquire the Patient Enrollment Form and access it in your editor.
2. Begin by entering your name in the designated field. It is essential to provide your full legal name as it appears on your identification documents.
3. Next, input your date of birth (DOB) in the specified format. Ensure that the information is accurate to avoid any processing issues.
4. Fill in your cell phone number. This will be the primary contact number for any communication regarding your enrollment.
5. Indicate if you have any known allergies by selecting 'Yes' or 'No'. If applicable, provide details in the space provided.
6. State whether you are being treated for an active infection. Select 'Yes' or 'No' based on your situation.
7. In the 'Patient Diagnosis' section, enter your medical diagnosis that necessitates PT/INR monitoring. This information is crucial for your treatment plan.
8. If you prefer to receive results via fax, select your fax option and provide the relevant fax number.
9. Complete the 'Notification of Panic Values' section by providing the required details, ensuring your healthcare team is alerted to urgent results.
10. Under 'Medical Necessity/Prescription', acknowledge the need for long-term arfarin therapy and confirm your understanding of self-testing requirements.
11. Ensure the physician’s signature is included if required, indicating professional approval for the self-testing service.
12. Finally, review all the entered information for accuracy. After verifying everything, you can proceed to save your changes, download, print, or share the completed form as needed.

Ready to manage your health? Complete your Patient Enrollment Form online today!