Name

Emergency Contact Name

Pt Rel

Patients Relationship to the Emergency Contact

Phone

Emergency Contact telephone number

School

School attended by patient

Phone

Telephone number of school

Status

Student Status (Full-Time, Part-Time, etc.)

Physician

Physician to default into Visits for the Patient

Referring

Referring Physician to default into Visits for the Patient

Surgeon

Surgeon to default into Visits for the Patient

Facility

Facility to default into Visits for the Patient

Hosp From

Beginning date of hospitalization

Hosp Thru

Ending date of hospitalization

Injury/Illness

Date of Injury or Illness

Drivers License

Patients drivers license number

Memo

A patient memo may be entered

Imaging

A image may be scanned and attached to this patient

Ok

Save changes to the database

Cancel

Close the form and do not save the changes (if any)