New Patient Forms

Complete Your Intake Packet Online

New patients can complete the intake packet online before their appointment. You can also download the PDF version if you prefer to print and complete it by hand.

Download PDF Packet Questions? Contact Us

Please do not use this form to submit urgent or emergency medical concerns.

Patient Information

Last Name *

First Name *

Middle Initial

Date of Birth

Age

Social Security Number

Sex

Address

City

State

ZIP Code

Cell Phone

Home Phone

Work Phone

Email *

How did you hear about us?

Responsible Party / Emergency Contact

Guarantor / Responsible Party

Relationship

Emergency Contact Name

Relationship

Emergency Contact Phone

Care Coordination

Preferred Pharmacy

Pharmacy City

Primary Care Physician

Phone

Date of Last Exam

Insurance and Authorization

Primary Insurance Company

Subscriber Name

Policy / Member ID

Group Number

Subscriber DOB

Relationship to Subscriber

Subscriber Employer

Secondary Insurance Company

Subscriber Name

Policy / Member ID

Group Number

Subscriber DOB

Relationship to Subscriber

Subscriber Employer

Health History

Personal Health History

Surgical History

Current Medications

Medication Allergies / Reactions

Family History and Lifestyle

Family Medical History

Other Family History Notes

Do you exercise?

Type

Are you dieting?

Type of Diet

Do you drink alcohol?

Drinks / Week

Do you use tobacco?

Tobacco Type

Cigarettes Pipe Cigars Chewing

How many per day

Packs per day

Quit Date

Consents and Acknowledgements

Records Release Preferences

Other

Fax transmission permitted

I confirm the information provided is true to the best of my knowledge and I consent to the listed authorizations and HIPAA-permitted uses.

Printed Name

Signature Name *

Signature Date

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