Patient Intake Form

PATIENT’S NAME

DATE OF BIRTH

AGE

SEX

M F

SOCIAL SECURITY

(if required)

NAME OF PARENT

(IF APPLICABLE)

NAME OF PERSON RESPONSIBLE FOR PAYMENT

(IF DIFFERENT THAN PATIENT)

MAILING ADDRESS

CITY STATE, ZIP

CELL PHONE

HOME PHONE

BUSINESS PHONE

EMPLOYER

FINANCIALLY RESPONSILBE PERSON

DRIVERS LICENCE # & STATE

PRIMARY INSURANCE

SECONDARY

NAME OF INSURED

DOB

SSN (if required)

MAY WE LEAVE A MESSAGE ON YOUR CELL PHONE

Y N

LIST PERSONS WITH WHOM WE CAN DISCUSS YOUR MEDICAL INFORMATION (WE CANNOT BE RELEASE INFORMATION TO ANYONE NOT LISTED ON THIS FORM)

Add Person

EMERGENCY CONTACT RELATIONSHIP

(spouse, sibling, etc.)

CELL PHONE

REFERRING PHYSICIAN

PRIMARY CARE PHYSICIAN

(if different from referring)

I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION TO MY REFERRING DOCTOR/PRIMARY CARE PROVIDER AND ANY DOCTOR THAT I MAY BE REFERRED TO. I AUTHORIZE MY REFERRING DOCTOR TO RELEASE MY MEDICAL RECORDS. I AUTHORIZE THE RELEASE OF MEDICAL RECORDS NEEDED TO PROCESSS INSURNACE CLAIMS. I AFFIRM ALL INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND ACCEPT FINANCIAL RESPONSIBILITY FOR SERVICES RENDERED.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

AUTHORIZED SIGNATURE

RELATIONSHIP TO PATIENT

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