Get Standford New Patient Intake/self-referral

Completing the Stanford New Patient Intake/Self-Referral form is an essential step in initiating your care at Stanford's Interventional Radiology department. This guide provides clear instructions to assist you in accurately filling out the form online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information. In the Name field, write your full legal name. Next, fill in your home phone number, cell phone number, and work phone number, ensuring you include the area codes where applicable.
3. Provide your address, including street, city, state, and zip code. Then, enter your date of birth and age.
4. Enter your email address to ensure easy communication regarding your care.
5. Fill out the Emergency Contact/Caregiver section with the name and contact number of someone who can be reached in case of an emergency. Also, indicate their relationship to you.
6. Answer the medical questions provided. In the section regarding why you would like to be seen by Interventional Radiology, clearly describe your reasons.
7. Detail any symptoms you are experiencing. Be as specific as possible to help the medical team understand your situation.
8. List any previous treatments you have undergone and the names of the healthcare professionals who provided those treatments.
9. Include any relevant recent imaging information, specifying the type of imaging and the date it was performed.
10. Indicate how you heard about the Stanford Interventional Radiology department.
11. Provide information regarding your referring provider, if applicable. Include their name, specialty, phone number, and, if you have one, the facility from which they operate.
12. If you do not have a referring provider, check the appropriate box provided.
13. Fill in your Primary Care Provider’s name, phone number, and optionally include the facility they are associated with.
14. Provide your insurance information, including the insurance company's name, type of policy, subscriber ID, group number, subscriber’s name, date of birth, relationship to the patient, and contact numbers for customer service and provider pre-certification.
15. Once all fields are completed, review your information for accuracy, then save your changes. You will have the option to download, print, or share the form as required.

Take the first step towards your care by completing your documents online today.