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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.

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sooryamkforstudy
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We take content rights seriously. If you suspect this is your content, claim it here.
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46 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

# 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

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