Preferences & Special Needs – Electronic Health Records Assoc.

Personal Information

Personal Information (EHR)

By default your Personal ID Number (PIN) should be in the first box by default every time.

If the Personal ID Number (PIN) box is left blank a new unique PIN will be generated for you.

Personal ID Number (PIN) - 12 digits
Enter new/updated information below and then press submit.
12 digit Personal ID Number (PIN)
Name*
First Last
Personal Health Number
Date of Birth
MM slash DD slash YYYY
Blood Type
- A
- B
- AB
- O
Rh Factor (for blood type)
- Positive
- Negative
Age
(years)
Gender
- Male
- Female
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email #1*
Email #2
Home Phone
Work Phone
Cell Phone #1
Cell Phone #2
Language Spoken
Comments
Photo
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.
Name
This field is for validation purposes and should be left unchanged.

Emergency Information

Emergency Contacts (EHR)

By default your Personal ID Number (PIN) should be in the first box by default every time.

If the Personal ID Number (PIN) box is left blank a new unique PIN will be generated for you.

Personal ID Number (PIN) - 12 digits
Please enter your Personal ID Number (PIN). If you do not have a PIN then leave blank and a unique PIN will be generated for you.
12 Digit Personal ID Number (PIN)
Emergency Contact - Primary
First Last
Primary Contact Relationship
Primary Contact Phone #1
Primary Contact Phone #2
Emergency Contact - Secondary
First Last
Secondary Contact Relationship
Secondary Contact Phone #1
Secondary Contact Phone #2
Comments

Employer Information

Employer Information (EHR)

Personal ID Number (PIN) - 12 digits
Please enter your Personal ID Number (PIN). If you do not have a PIN then leave blank and a unique PIN will be generated for you.
12 Digit Personal ID Number (PIN)
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone
Current Occupation
Comments

Insurance Information

Insurance Information (EHR)

Legal Information

Legal (EHR)

Preferences and Special Needs

Personal Information (EHR)

Emergency Contacts (EHR)

Employer Information (EHR)

Insurance Information (EHR)

Legal (EHR)

Preferences and Special Needs (EHR)

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