Patient Registration Form Occupational Medicine - Freedom Urgent ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and date at the top of the form. Ensure that all information is printed clearly.
3. Fill in your date of birth and Social Security Number (SSN) accurately, as this information is crucial for identification purposes.
4. Complete the demographic section by providing your race, age, and sex. This data helps in understanding patient diversity.
5. Input your mailing address, including city, state, and ZIP code. Double-check for accuracy to ensure proper communication.
6. Provide both home and cell phone numbers for contact purposes. Make sure these are current and reachable.
7. Indicate any barriers to communication that may affect understanding of health information. This ensures you receive appropriate support.
8. Select the reason for your visit by checking the appropriate box: injury, physical, drug screen only, or other. Provide additional details if necessary.
9. Fill in your company name and supervisor's details if applicable, along with the date of injury if relevant.
10. Finally, verify that all provided information is accurate before signing and dating the form at the bottom.

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