Medium

Available on

Apple Android Windows

Patient Information and Financial Policy Mobile App

This app covers the basic patient information as well as the patient's insurance and therefore authorizes medical professionals to perform given work under the permission of the patient. In this application, the patient declares responsibility of paying medical fees for treatments in the event they are not covered by the insurance.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Patient Information and Financial Policy Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Patient Name (Last, First, Mid)

  • Ico textbox

    Responsible Party

  • Ico textbox

    Address

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip

  • Ico textbox

    Patient SS#

  • Ico textbox

    Date of Birth

  • Ico dropdown

    Patient's Sex

  • Ico textbox

    Marital Status

  • Ico textbox

    Home Phone Number

  • Ico textbox

    Name of Prescribing Physician

  • Ico textbox

    Name of Family Physician

  • Ico textbox

    Spouse's Name

  • Ico textbox

    Employer

  • Ico textbox

    Position

  • Ico multiline

    Address

  • Ico textbox

    Work Phone Number

  • Ico textbox

    Nearest Relative Not Living With You

  • Ico textbox

    Relationship

  • Ico multiline

    Address

  • Ico textbox

    Phone Number

  • Ico textbox

    Who Should We Contact in Case of Emergency?

  • Ico textbox

    Relationship

  • Ico multiline

    Address

  • Ico multiline

    Phone Number

  • Ico statictext

    If This is an Injury as a Result of an Accident

  • Ico date

    Date of Injury

  • ...and More!

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