Patient Intake Form New Patient Registration and Medical History
1. Personal Information Please provide your complete personal information below. All information will be kept confidential in accordance with HIPAA regulations and used solely for your medical care and treatment.
2. Emergency Contact Please provide the name and contact information for a person we may contact in case of emergency. This person should be someone who is aware of your medical conditions and can make decisions on your behalf if necessary.
3. Insurance Information Please provide your current insurance information. If you have secondary insurance, please provide that information as well. A copy of your insurance card will be requested at check-in.
4. Medical History Please list any current medications, known allergies, previous surgeries, and chronic conditions. Include the names of any other healthcare providers currently treating you. This information is essential for safe and effective care.
5. Consent to Treatment By signing below, I consent to receive medical examination and treatment as deemed necessary by the healthcare provider. I understand that I may withdraw consent at any time. Patient Intake Form (continued)
Patient Name:
Date of Birth:
Phone:
Emergency Contact:
Insurance Provider:
Policy Number:
Patient Signature Date
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