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Click ‘Get Form’ to open it in the editor.
Begin by entering your Patient Name and DOB at the top of the form. This information is essential for identifying your medical records.
Proceed to the Medical History section. For each condition listed, mark 'Yes' or 'No' as applicable. If you answer 'Yes', provide additional details where prompted, such as the year diagnosed or previous doctors.
Continue through each section, including Heart, Respiratory, Gastrointestinal, and others. Ensure you fill in all relevant fields accurately to provide a comprehensive medical history.
Once all sections are completed, click the 'Save Form' button to save your progress. If using Google Chrome, right-click on the form and select 'Save As...' to download it.
Finally, send the completed form via email to medicalrecords@ganephrology.com for processing.
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