Patient Intake Form

Please Note

Once benefits are verified, the office manager will reach out to let you know and to inform you of deductible amount, copay, and coinsurance percentage. Please provide all insurance information. The provider's office is not responsible for unpaid claims due to the client not providing all information. Please keep the office updated about any changes to your insurance plan and/or demographic information.

Full Name

Date of Birth

Name of Responsible Party

Date of Birth of RP

Full Address

Phone Number

Email address

Preferred Method of Contact

Phone Call

Text Message

SSN (If Tricare, please include Sponsors)

Insurance Name

Insurance Phone Number

ID Number

Group Number

Secondary Insurance Name

Insurance Phone Number

ID Number

Group Number

Files Please upload the front and back of your insurance card.

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Patient Intake Form

Please Note

Please Note

Vickie Purdy, LPC