Patient - DoctorWanda . org Doctor Wanda - doctorwanda 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient' section with your name, referral source, and contact information including mailing address, phone number, city, state, and zip code.
3. Complete the 'Employer' and 'Birthdate' fields. Indicate your marital status by circling the appropriate option.
4. Provide your Social Security number and details of your spouse or guardian if applicable. Include their contact information as well.
5. In the 'PRIMARY INSURANCE' section, circle the correct option for who holds the insurance. Fill in the insured's name, date of birth, insurance company details, and identification numbers.
6. Sign and date where indicated to acknowledge payment terms and consent for direct payment to Doctor Johnson-Roberts.
7. Review the confidentiality section carefully before signing to ensure you understand your rights regarding information release.
8. Lastly, complete any additional sections such as appointment policies or medication lists as required.

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