Concentra Patient Information Form 2025

1. Click ‘Get Form’ to open the Concentra Patient Information Form in our platform.
2. Begin by filling out the 'About You' section. Enter your last name, first name, middle initial, date of birth, and contact information including home phone, work phone, and cell phone.
3. Indicate the reason for your visit by selecting from options such as injury care, physical exam, or drug screen. Provide your social security number or military DBN if applicable.
4. In the 'About Your Employer' section, enter your employer's company name and address. If applicable, indicate if you are employed through a temporary hire agency and provide the agency's details.
5. Review the Notice of Privacy Practices section. Acknowledge receipt by printing your name and signing with the date received.
6. Complete the Consent section by confirming that all information is accurate. Sign and date to give permission for necessary medical services.

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