LOSATS Patient Intake Form

Questions?

We would be happy to answer any questions you may have regarding this form. Please call us at: (585) 586-6840

Today's Date

Patient Information

Person Calling:

First Name

Last Name

Date of Birth

Phone Number

Type of Phone

Cell Phone Landline

Email Address

Address

City

State

Zip Code:

Name of Employer or School

Grade Level

Employer or School Phone Number

Diagnosis (if known)

Referred By

Phone Number

Reason for Referral

Person Responsible for Payment

(If other than the patient)

First Name

Last Name

Relationship to Patient

Address

City

State

Zip Code

Home Phone Number

Work Phone Number

Insurance Information

Insurance Provider

Subscriber ID Number

Name of Subscriber

Date of Birth

Relation to Patient

Effective Date

Copay/Deductible (if known)

Bill Claims to

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LOSATS Patient Intake Form

Questions?

Patient Information

Person Responsible for Payment

Insurance Information

Questions?

Linden Oaks Specialized Assessment and Treatment Services (LOSATS)