Thanks to visit codestin.com
Credit goes to www.scribd.com

Scribd
Upload
10 views3 pages

Document 1

The document is a Patient Intake Form that collects essential information from patients, including personal details, emergency contact, insurance information, referral sources, and reasons for the visit. It also includes a consent section for the accuracy of the information provided and authorization for insurance claims. The form is structured to ensure comprehensive data collection for medical services.

Uploaded by

sooryamkforstudy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
10 views3 pages

Document 1

The document is a Patient Intake Form that collects essential information from patients, including personal details, emergency contact, insurance information, referral sources, and reasons for the visit. It also includes a consent section for the accuracy of the information provided and authorization for insurance claims. The form is structured to ensure comprehensive data collection for medical services.

Uploaded by

sooryamkforstudy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

# PATIENT INTAKE FORM

## PATIENT INFORMATION

**Date:** _____/_____/_____

**Patient Name:** _______________________________ **Date of Birth:** _____/_____/_____

Last First MI

**Sex:** □ Male □ Female □ Other **SSN:** _______-_______-_______

**Address:** ____________________________________________________________________

Street Apt/Unit #

City State ZIP Code

**Phone:** (______) ______-________ □ Cell □ Home □ Work

**Email:** ____________________________________________________________________

**Preferred Contact Method:** □ Phone □ Email □ Text

**Marital Status:** □ Single □ Married □ Divorced □ Widowed □ Separated

**Employment Status:** □ Full Time □ Part Time □ Not Employed □ Retired □ Student

**Employer/School:** __________________________ **Occupation:** __________________


## EMERGENCY CONTACT

**Name:** ________________________________ **Relationship:** __________________

**Phone:** (______) ______-________

## INSURANCE INFORMATION

**Primary Insurance:** __________________________________________________________

**Policy Holder Name:** ________________________ **Date of Birth:** _____/_____/_____

**Policy #:** _________________________________ **Group #:** ___________________

**Secondary Insurance:** _______________________________________________________

**Policy Holder Name:** ________________________ **Date of Birth:** _____/_____/_____

**Policy #:** _________________________________ **Group #:** ___________________

## REFERRAL INFORMATION

**How did you hear about us?**

□ Doctor Referral □ Insurance □ Family/Friend □ Internet □ Other: ______________


**Referring Physician:** _________________________ **Phone:** (______) ______-________

## REASON FOR VISIT

**Primary Concern/Symptoms:** __________________________________________________

**Date Symptoms Began:** _____/_____/_____

**Have you seen another provider for this issue?** □ Yes □ No

## CONSENT AND ACKNOWLEDGEMENT

I certify that the information provided is accurate and complete to the best of my
knowledge. I authorize the release of any medical information necessary to process
insurance claims and authorize payment of medical benefits to the physician or supplier
for services rendered.

**Signature:** _______________________________________ **Date:** _____/_____/_____

**Print Name:** _______________________________________

□ Patient □ Parent □ Legal Guardian

You might also like