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1. Click ‘Get Form’ to open the International Patient Information Form in the editor.
2. Begin by entering your contact information. Fill in your name, date of birth, sex, and U.S. Social Security number if applicable. Provide your foreign address and contact details including telephone, cellular, fax, and email.
3. Next, complete the U.S. address for billing if you have one. If not, leave this section blank as instructed.
4. In the Patient Employment Information section, input your employer's name, occupation, address, and contact numbers.
5. If applicable, provide details for a U.S. contact person including their relationship to you and their contact information.
6. For Medical Information, state your diagnosis and remember to attach any required medical records in PDF format directly through our platform.
7. Indicate any special appointment requests or patient availability as needed.
8. Fill out the International Insurance section if you have insurance that can be billed; ensure to attach photocopies of your insurance cards.
9. Lastly, provide referral information detailing who referred you and how you heard about the services offered.

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