Please present this form to Cabell Huntington Hospital - cabellhuntington 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient's Name in the designated field. Ensure that the name matches the identification provided.
3. Fill in the Date of Birth and Phone number accurately to avoid any discrepancies.
4. Complete the Address section with your current residential information, ensuring all lines are filled out.
5. Indicate if this is a self-enrollment by answering the question provided. Note that self-enrollment is not available for patients under 18.
6. If applicable, provide details about the primary custodian for minors under 14, including their Name/Relationship and Email.
7. If you are a legal representative, ensure you attach any required legal documentation and fill out the corresponding fields for custodian information.
8. Sign and date the form at the bottom, confirming that all information is accurate. A witness signature is also required.

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