Get Physician Information Hospital ... - Broward Sheriff's Office - Sheriff

Filling out the PHYSICIAN INFORMATION HOSPITAL form is essential to ensure that medical professionals have the most accurate and current information regarding your child's medical history. This comprehensive guide will walk you through the necessary steps to complete the form accurately and effectively.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your child's name and date of birth (DOB) in the designated fields. Be sure to select the child's gender by marking either 'Male' or 'Female.'
3. Fill in the home address, including street address, apartment or unit number (if applicable), city, state (Florida), and zip code.
4. Provide your name and indicate your relationship to the child by selecting 'Parent,' 'Guardian,' or 'Other.' If you select 'Other,' please specify your relationship.
5. List two emergency contact persons, including their names and phone numbers. This information is crucial for immediate communication during emergencies.
6. Enter the primary care physician's name, phone number, and fax number in the 'PHYSICIAN INFORMATION' section. Repeat this for any specialty or additional physicians as needed.
7. In the 'HOSPITAL INFORMATION' section, indicate which hospital's emergency department has evaluated and treated your child. Additionally, specify the hospital of choice for potential hospitalization.
8. Detail the child's medical history by entering their current diagnosis. Include information about any advanced technology devices, procedures to avoid, and why these procedures should be avoided.
9. List all medications your child is currently taking, including the dosage for each medication.
10. Document any allergies your child has, including medication allergies, food allergies, and other allergies.
11. Identify common presenting problems and suggested management considerations for each problem faced by your child.
12. Finally, sign the form, indicate your relationship to the child, and date the form. Ensure all information is accurate and complete.
13. Once you've finished filling out the form, you can save your changes, download, print, or share the completed form as needed.

Complete your PHYSICIAN INFORMATION HOSPITAL form online today to ensure accurate and timely medical information is available for your child.