New Patient Intake Form

This form MUST be completed before you arrive for your Day One appointment. If it is not your appointment will be rescheduled. If you would prefer to use our interactive PDF or print out your paperwork and complete by hand - please click here.

 
Patient Name *
Patient Name
Today's Date *
Today's Date
Primary Phone *
Primary Phone
Cell Phone
Cell Phone
If different than primary
Date of Birth *
Date of Birth
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
In case of a medical emergency, if the patient is of school age 15+, it is ok to treat in my absense
Responsible Party - skip if same as above
Name of the the person responsible for this account
Name of the the person responsible for this account
Primary Phone
Primary Phone
Cell Phone
Cell Phone
If different from primary
Date of Birth
Date of Birth
If yes, complete the section below
Name of the Insured *
Name of the Insured
Birthdate *
Birthdate
Work Phone *
Work Phone
Health History
Patient Name *
Patient Name
Date of Birth *
Date of Birth
Past Medical History *
(Have you ever had the following: (check for “yes” or leave blank if "no" or you are uncertain.)
Put "none" if there is nothing else
Put N/A if you've never had one
What, When & What Hospital, City & State
Indclude nonprescription
Patient Social History
Family Medical History
Age, Disease History, If Deceased - cause of death
Age, Disease History, If Deceased - cause of death
Age, Disease History, If Deceased - cause of death
Age, Disease History, If Deceased - cause of death
Age, Disease History, If Deceased - cause of death
Age, Disease History, If Deceased - cause of death
Age, Disease History, If Deceased - cause of death
Indicate which of the below you have experienced recently.
Name of Patient, Parent or Guardian *
Name of Patient, Parent or Guardian
This will count as your signature to the above statement