New Patient Forms Packet – Nephrology Specialists of Oklahoma

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Basic Information & Patient Consent

Name

First Name

Last Name

Date of Birth

SSN

Address

City

State/Province

Zip/Postal

Country

Home Phone

Cell Phone

Sex

Male

Female

Race

Black/African American

Native American

White/Caucasian

OtherOther

Ethnicity

Hispanic

Non-Hispanic

Language

English

Spanish

OtherOther

Spouse's Information

Name

First Name

Last Name

Date of Birth

SSN

Emergency Contact Information

A maximum of 2 emergency contact persons only.

Name

Phone

Relationship

Add Remove

Primary Care Physician

Name

First Name

Last Name

Phone

Fax

Address

City

State/Province

Zip/Postal

Country

CONSENT FOR ROUTINE MEDICAL TREATMENT: Nephrology Specialists of Oklahoma and its employees are hereby authorized to collect medical history information; obtain vital signs and perform other routine procedures for the purpose of providing care to you. You have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency, or extraordinary circumstances. Under emergency circumstances, we will take necessary and available actions to meet your medical needs.

By checking this box you acknowledge that you have read and understood the contents of this form.

Patient/Authorized Signature

Clear

Relation to Patient

Date

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