Patient Belongings Inventory Form

1

Patient Name

First Name

Last Name

2

Social security number

3

Contact number

Please enter a valid phone number.

4

Items list

5

I {patientName} with the SSN {socialSecurity}, fully understand that by signing below, I {patientName} am aware of the policy of inventory management policy and verify that the items listed above as inventory are correct.

6

Signature

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