SCMH ER Patient intake (Blank)

Patient Record -
Physician of SCMC-
Date of Visit:


Name:
Address:
Occupation:
Date of Birth:
ID Verified By**:

Reason for Visit:
________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may cause severe penalties per the laws of San Carlos
that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35 and will be severely punished.

Verification
Signature: Date:


Admission Signature:

(It is presumed that all patients have Insurance)