Intake Form (Adult)

Emergency Assistance

If this is an emergency, call 911 or go to the nearest Emergency Department

Patient Data

Last name

Middle Name

First name

Date of birth

SSN

Encrypted

If Minor: Parent or Guardian Information

Name, DOB, Phone, Address

Sexual Orientation & Gender Identity

Heterosexual (attraction to a different gender), Homosexual (attraction to the same gender, including gay and lesbian), Bisexual (attraction to more than one gender), Pansexual (attraction regardless of gender), and Asexual (little to no sexual attraction)

Address

Street, City, State, Zip

Phone number

Alt Phone number

Email address

Smoking History

How Much?

Years Smoked, Quantity per day.

Medical History

Have you been treated by a provider in the last 12 months?

Yes No

Provider name or facility

If yes, please describe the reason for your visit

Date of your last physical exam

Is there a chance that you are pregnant? FEMALES

Yes No

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Can also submit copy of list on upload page.

Please list all the conditions that you have been diagnosed with.

Please list previous major surgeries.

Do you have any allergies to medications?

Occupation

Emergency Contact Information/ Next of Kin

Add another emergency contact

Primary Insurance Name, Secondary Insurance, Third Insurance

Attach copies of front and back to document uploader

Files

Add file

Please upload a file

Your information will be encrypted.