Patient Qualification Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Email
*
example@example.com
I agree to receive text messages from On Aid Care for business purposes
Yes
Upon contact, what is your preferred language?
*
English
Spanish
French
Portuguese
Describe your Wound...
Attestation
I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form.
Patient or Proxy for Patient Signature
Proxy for Patient
First Name
Last Name
Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for the return or destruction of these documents.
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