Get Name Date Personal Demographics - Healthcare Utah

Filling out the Name Date Personal Demographics form is a crucial step in the healthcare process, particularly for those seeking bariatric surgery. This guide offers clear instructions and insights to help you complete the form with ease and accuracy.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the document and open it in the online editor.
2. Begin by entering your last name, first name, and middle initial (MI) in the designated fields. If applicable, include your maiden name for reference.
3. Provide your current address, along with your city, state, and zip code.
4. Indicate your home, cell, and work phone numbers. Be sure to select the best contact number for daytime communication by marking the corresponding checkbox.
5. Specify your gender by selecting either 'male' or 'female'. Input your date of birth in the relevant field.
6. Select your marital status from the options provided: married, divorced, widowed, separated, or never married.
7. Identify your race by checking the appropriate box next to options such as white, African American, Hispanic, Asian, Native American/Alaskan Native, or other, and provide additional details if necessary.
8. Enter your email address, if you wish to receive communications via email.
9. Fill out your employer's name and your current occupation.
10. If applicable, complete the spouse information section, including their last name, first name, phone number, and employer.
11. Provide information regarding your primary insurance company, policyholder’s name, relation to the patient, policy number, group/plan number, and contact numbers for customer service and provider inquiry.
12. Repeat step 11 for your secondary insurance company, if applicable.
13. Mark your preferred type of surgery or indicate if you have not decided by ticking the corresponding box.
14. Document details about your primary and referring physicians, including their names, addresses, and phone numbers.
15. Compose a personal statement elaborating on your reasons for requesting weight loss surgery. Utilize the back of the form if you require more space.
16. Complete the sections regarding your diet history, medical information, family history, social history, pregnancies, review of systems, allergies, and medications, ensuring all relevant details are captured.
17. After you have filled out all sections of the form, review your information for accuracy and completeness.
18. Save your changes, download, print, or share the completed form as needed.

Take the next step in your healthcare journey by completing your documents online today.