EEOC2

Confidential Equal Opportunity Employer Information

(Will not be shared with LifeScape prior to beginning employment.)

Patient Information:

This completed form serves as a medical script which is required to schedule a patient appointment.

Parent/Guardian Name: (required if patient is under 18 years of age)

Date of Birth:

Gender: M F

Primary Phone Number:

Interpreter Needed? Yes No

Name:

This Visit is: (*For urgent appointments, please call us at 605.444.9700 or 800.584.9294) Routine (Next Available) Semi-Urgent* (Within Two Weeks) Urgent* (Less Than 48 Hours)

Patient's Medical Issue:

Please tell us what specific medical issue to address at this visit:

Upload Prescription or Referral Document

File Size Limit: 10 MB – File Types: PDF, Word Document, or Image Files

Referring Provider Information

Hospital/Clinic:

Provider Name:

City, State:

Phone:

Email:

This site is secured and any documents accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation. 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 and arrange for the return or destruction of these documents. This form is authorization for use or disclosure of Protected Health Information. By selecting the "Submit" button, you are signing this Form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "Submit" you consent to be legally bound by this Agreement's terms and conditions.