Get Tx Pdlabs Plantar Fibromatosis New Patient Form 2016-2025

This guide provides comprehensive instructions to assist you in completing the TX PDLabs Plantar Fibromatosis New Patient Form online. By following these steps, you will ensure that all necessary information is accurately submitted, facilitating a smooth process for your new patient registration.

Follow the steps to effectively complete the form.

1. Click the ‘Get Form’ button to access the form and open it in your browser.
2. Begin by filling out the physician information section. Include the physician's organization, name, DEA number, NPI number, address, city, state, zip code, phone number, fax number, and email address.
3. Proceed to the patient information section. Indicate the patient's name, email address, date of birth, address, city, state, zip code, and phone number. Specify the patient’s gender by selecting either male or female.
4. Provide HIPAA contact information in the designated field. This should include names or titles of individuals authorized to receive patient information.
5. List any medications the patient is currently taking in the medications field, ensuring to include all relevant information.
6. Record any known allergies in the allergies section.
7. Indicate if there is a family history of plantar fibromatosis and if the patient has undergone prior surgery pertaining to this condition.
8. Fill out the ‘Time with condition’ field to provide how long the patient has been experiencing symptoms.
9. For each foot, please rate the pain on a scale of 1 to 10 and note the presence of nodules. Provide the size of each nodule where applicable.
10. Tick the box indicating which foot(s) will be treated with Transdermal 15% Gel and document the requested number of refills.
11. Complete the physician’s signature section and record the date to validate the prescription.
12. Finally, save your changes, download the completed form, print it for documentation, or share it as required.

Complete your TX PDLabs Plantar Fibromatosis New Patient Form online today!