Get Ri Dlt Arrigan Rehabilitation Center - Patient Information Intake Form_dsa

Completing the RI DLT Arrigan Rehabilitation Center - Patient Information Intake Form_DSA online is an essential step in your admission process. This guide will provide you with clear, step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to successfully complete your intake form online.

1. Press the ‘Get Form’ button to access the form and open it in your chosen online editor.
2. Fill in your personal details, including your name, date of birth (DOB), email address, home phone number, and cell phone number.
3. Input your current residential address, including street address, city, state, and zip code.
4. Provide the name and contact information of an emergency contact, including their relationship to you and their phone number.
5. Enter the details of your family physician, including their name, address, and phone number.
6. Fill out information regarding your physician for injury, including their name, address, and phone number.
7. Indicate the length of time you have been with your employer prior to your injury and any weekly amount of workers’ compensation that you are receiving (if applicable).
8. Specify your occupation and the last day you worked, along with the date of your injury.
9. List the names, addresses, and phone numbers of all doctors you want to receive your reports, along with any additional requests for case managers.
10. Include the name and contact information of your attorney, if applicable.
11. Indicate whether you have previously visited the Arrigan Center and the date of your last visit, if applicable.
12. Answer the questions regarding whether you received an information letter from the Arrigan Center.
13. Provide your height and weight, and answer the past medical history questions by checking all applicable conditions.
14. List any current medications you are taking, including dosages.
15. Document any previous surgeries, including their dates.
16. Indicate any recent symptoms you may be experiencing by checking the relevant boxes.
17. List any known allergies to medications.
18. Provide details about your social history, such as alcohol and drug use, smoking status, marital status, and number of children.
19. Indicate whether anyone in your family has a history of heart disease.
20. After completing the form, review all entries for accuracy. You can then save changes, download, print, or share the form as needed.

Begin filling out your patient information intake form online today to ensure a smooth admission process.