Get Uw Fas Clinic New Patient Information Form 2012-2025

Completing the UW Fas Clinic New Patient Information Form online is an essential step in scheduling an appointment for evaluation and care. This guide provides clear instructions to help you navigate each section of the form effectively.

Follow the steps to complete the form

1. Click ‘Get Form’ button to obtain the New Patient Information Form and open it for editing.
2. Begin by filling out the patient identification section, which includes the patient's name, birth date, age, address, and contact information. Ensure all entries are accurate to avoid delays in processing.
3. Next, complete the caregiver identification section. Provide the name and relationship of the patient’s primary caregiver, including their contact information. This helps establish communication channels.
4. In the section for the person completing the form, provide your name, relationship to the patient, and any referral source information. This identifies who is submitting the form on behalf of the patient.
5. Fill out the legal guardian information, which is required. Ensure this section is accurate and complete to meet legal requirements.
6. Detail the reasons for evaluation by specifying the patient’s primary problems and what you hope to achieve from the evaluation.
7. Provide birth measures, including weight, length, and head circumference. This information is crucial for accurate assessment.
8. Next, address the section regarding physical appearance and health, including any known birth defects and chronic health issues.
9. Complete the neurological issues and attention deficit and hyperactivity sections, clearly noting any relevant medical history.
10. Fill out the mental health issues section, providing information about any previous mental health evaluations and treatments.
11. Document school issues by listing all schools attended and grades along with any special education services received.
12. In the alcohol exposure section, provide detailed information about the birth mother's alcohol use during and before pregnancy, as this is critical for diagnosis.
13. Complete the information about the patient's biological parents and any medical history relevant to the patient’s family.
14. After addressing any additional sections, review the entire form for completeness and clarity.
15. Save your changes, download the form for your records, and print or share as required. Ensure that any requested photographs are attached before submission.

Complete the UW Fas Clinic New Patient Information Form online to schedule your appointment today.