Get Directory Form.doc - My Clevelandclinic

Filling out the Directory Form for the Pediatric Epilepsy Support Group is a straightforward process designed to help families connect with others in similar situations. This guide provides clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to fill out the Directory Form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out your name in the designated field. This information will help connect you with other families.
3. Next, complete your address by providing your street address, city, state, and zip code. Ensure that each section is filled out completely for accurate communication.
4. Provide your home telephone number and an alternate telephone number in the respective fields. This allows for multiple ways to reach you if necessary.
5. Enter your email address in the provided field. This will be an important means of communication regarding the directory.
6. Fill in the name of the patient. This identifies whom the directory entry pertains to.
7. Specify the surgical procedure that the patient underwent. This information helps personalize the directory experience.
8. Confirm your approval for the release of the personal information by checking the box provided. This is necessary to share your information with other families in the directory.
9. Provide your signature and the date on which you are completing the form. This is a legal requirement that confirms your consent.
10. Indicate your relationship to the patient in the appropriate field. This helps clarify your connection to the information provided.
11. Set an expiration date for the authorization if required. This ensures that you retain control over the duration of your information’s availability.
12. Complete the mailing address section if it differs from your residential address. This is where the completed form will be sent.
13. Once completed, mail the form to Dr. Deepak Lachhwani at the Cleveland Clinic Foundation. Remember to keep a copy for your records.

Complete the Directory Form online today to connect with other families and foster a supportive community.