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Click ‘Get Form’ to open the face sheet in the editor.
Begin by filling out the Patient Demographics section. Enter the patient's last name, sex, date of birth (DOB), age, and first and middle names. Ensure you select the correct marital status and provide the address details.
Complete the Ethnic Origin field by selecting one of the options provided. Fill in additional information such as home phone, cell phone, vehicle details, employer name, and social security number.
Proceed to Section 2 for Guarantor/Legal Guardian details. Input their last name, first name, cell phone, religion, and address information.
In Section 3, provide Primary Insurance Information including the insurance name and policy number. If applicable, complete Section 4 for Secondary Insurance.
Fill out emergency contact details in Section 5. Include two contacts with their relationship to the patient and all relevant phone numbers.
Finally, answer questions regarding previous hospitalizations and how you heard about Sundance Hospital in Sections 6 and 7 respectively.
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