Follow the steps to complete the patient information form with ease.

1. Click ‘Get Form’ button to access the form and open it.
2. Begin by entering your personal information, including your first name, middle initial, and last name. Ensure that the name matches your identification.
3. Provide your social security number or military DBN followed by your date of birth in MM/DD/YYYY format.
4. Fill in your address, including apartment number (if applicable), city, state, and ZIP code.
5. List your phone numbers: home phone, cell phone, and work phone. Indicate your preferred method of contact by selecting the appropriate options.
6. For gender identification, select either male or female as applicable.
7. Indicate your marital status by selecting single or married.
8. Choose whether you consent to receive emails from Concentra by selecting yes or no.
9. Consent to receive text messages by providing your personal cell phone number and understanding the implications of this consent.
10. Sign and date the form where indicated under the signature section for verification and consent to treatment.
11. Move to the ‘About Your Employer’ section and enter the company name, address, and location/store number.
12. If applicable, indicate if your employment is arranged through a temporary hire agency by selecting yes or no and providing the agency name.
13. Acknowledge that you have received the Notice of Privacy Practices by printing your name, signing, and dating the section provided.
14. If not here solely for a DOT drug screen or breath alcohol test, complete the consent section by providing accurate information and signing the form.
15. Review your entries for accuracy before saving, downloading, printing, or sharing the completed form.

Complete your Concentra Employer Services Patient Information form online today!