01. Edit your impilo patient information form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send impilo patient information via email, link, or fax. You can also download it, export it or print it out.
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Click ‘Get Form’ to open the impilo patient information form in the editor.
Begin by filling out the 'Patient Information' section. Enter your surname, name, initials, and any other names you are known by. Select your title and provide your mobile number, gender, date of birth, and preferred method of contact.
Complete the 'Emergency Contact' section by providing details for a person to be contacted in case of a medical emergency. Include their relationship to you, mobile number, and address.
In the 'Medical Aid Information' section, input your medical aid scheme details including member number and principal member's information.
Fill out the 'Clinical Information' section with a brief description of your symptoms and any chronic conditions you may have.
Finally, review all entered information for accuracy before signing at the bottom of the form to confirm that it is true and correct.
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These include (but are not limited to) spoken PHI, PHI written on paper, electronic PHI, and physical or digital images that could identify the subject of health information.
What is considered patient information?
Examples of PHI Certificate/license number. Vehicle identifiers, serial numbers, or license plate numbers. Device identifiers or serial numbers. Web URLs. IP address. Biometric identifiers such as fingerprints or voice prints. Full-face photos. Any other unique identifying numbers, characteristics, or codes.
How to make a patient information sheet?
Keep to small paragraphs of understandable text. Use short sentences, usually no more than 15 to 20 words. Be careful not to use language that could be read as discriminatory or stereotyping. Avoid using all upper case letters, italics and underlining; use bold for emphasis.
What information may be included on a patient registration form?
The information collected during patient registration includes personal details such as name, address, contact information, date of birth, social security number, insurance details, medical history, and any relevant medical conditions or allergies.
What documents a patients admission to the hospital?
Admission notes can include any clinical documents completed during a patients admission to hospital. Weve covered the formal admission note in this article, but other documents completed at admission may include a patient intake form, medical consent form, history of present illness (HPI), and nursing notes.
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What are examples of patient information?
Patient Information Sheet. Patient Information. Last Name. First Name. MI. Address. Employer. Employment Status Employed Self-employed Retired On active military duty Unknown. Employer Name. Employer Address. Employer phone. Emergency Contact Information. Name. Relationship to Patient. Home or Work Phone. Insurance.
What is an example of patient information?
Patient data and information administrative details of appointments, or whether they are waiting for a place in a health and care setting such as a care home or hospital ward. medical information such as symptoms, diagnosis, weight, medicines, treatments and allergies.
Related links
Study Details | TholImpilo: Bringing People Into Care
A type of observational study that collects information about patients medical conditions and/or treatments to better understand how a condition or treatment
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