Home
Faq’s
About
Contact
Services
Policy
Patient Form

Patient Form

Personal Information

Full Name

Date of Birth

Gender

Male

Female

Other

Prefer not to say

Address

City

Phone Number (Cell)

Phone Number (Home)

Preferred Contact Method

Phone

Text Message

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Emergency Contact

Insurance Information

Primary Insurance Carrier:

Policy Number

Group Number (if applicable):

Subscriber Name (if not the patient)

Subscriber Date of Birth (if not the patient)

Secondary Insurance (if applicable):

Policy Number (if applicable)

Medical History

Primary Care Physician (if applicable)

Previous Medical Provider (if applicable)

Reason for Seeking Care:

Have you ever been diagnosed with any of the following?

List any major surgeries or hospitalizations

Current Medications (including over-the-counter drugs, supplements, etc.)

Allergies (medications, food, environmental, etc.)

Family History

• Do any of your family members have a history of the following? (Check all that apply)

Lifestyle and Social History

Do you smoke?

Yes

Do you drink alcohol?

Yes

Do you use recreational drugs?

Yes

Do you exercise regularly?

Yes

Dietary habits:

Healthy balanced diet

Fast food or processed food

Vegetarian

Vegan

Other

Current Health Concerns

What symptoms or health concerns are you experiencing today?

Consent and Acknowledgement

By signing below, I acknowledge that the information provided is accurate to the best of my knowledge. I authorize the primary care practice to provide medical care and treatment as deemed necessary by my healthcare provider. I consent to the use of my health information as required for medical treatment and in accordance with privacy laws.

Patient Signature

Date

This intake form covers the basic medical and personal information needed to begin care for new patients. Be sure to adjust and personalize the form based on your practice’s specific requirements and state regulations.

Nurse's Square

LinkedIn
Facebook
Instagram