Intake Form
Please answer each question if applicable. Your answers are private and secure.
Patient's full name
Your answer
Date of birth *
MM-DD-YYYY
Your answer
Gender *
Your answer
SSN
XXX-XX-XXXX
Your answer
Phone *
Indicate if it is a cell phone or landline
Your answer
E-mail *
Your answer
Prefered choice(s) of communication
Call, Text and/or E-Mail
Street address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Insurance + Payment Preference *
Required
Primary Insurance Name
We are currently not accepting True Blue/Blue Cross Medicare Advantage plan.
Your answer
Plan Name & Type
HMO, PPO, etc
Your answer
Insurance ID
Your answer
Group ID
Your answer
Effective From *
MM/DD/YYYY
Your answer
Effective To
MM/DD/YYYY
Your answer
Copay $ Amount
Your answer
How are you related to the insurance subscriber?
Insurance Subscriber's Name
Your answer
Subscriber's Date of Birth
MM/DD/YYYY
Your answer
Subscriber's Address
Your answer
Subscriber's Employer Providing Insurance
Ex: Micron, Ada County, Idaho Power, SARMC
Your answer
Claim number
If applicable for workman's comp
Your answer
Any additional insurance information please provide here
Your answer
Preferred Pharmacy *
Please provide cross streets or address.
Your answer
DEMOGRAPHICS
Ethnicity/Race
Preferred Language
Next of kin/emergency contact name *
Your answer
Next of kin/emergency contact relationship to patient *
Your answer
Next of kin/emergency contact phone number *
Your answer
Next of kin/emergency contact address *
Street, City, State, zip
Your answer
Please share how you heard about us.
Facebook, Friend, Google Search, etc.
Your answer
MEDICAL HISTORY
Medication Allergies *
Your answer
Type of Allergic Reaction to Medication Listed Above
Example: Rash, Itching, Anaphylaxis
Your answer
Allergic Reaction Severity to Above Listed Medication
Medications *
Name | Strength | Times per day. Example: Lisinopril 40 mg once a day
Your answer
Smoking history *
Never Smoked/Current smoker not interested in quitting/Ex-Smoker/Current Smoker, interested in quitting
Gender identity
Sexual orientation
Past Medical History *
Example: Hypertension, Cancer, COPD, Diabetes
Your answer
Past Surgical History *
Example: Appendectomy, C-Section, Tonsillectomy
Your answer
Obstetrical History
# Total Pregnancies |# Live Births | # Miscarriages
Your answer
Height
Your answer
Weight (lbs)
Your answer
Mother's medical history
Your answer
Father's medical history
Your answer
Other immediate family member's (brothers/sisters) health history
Cancer, Heart Disease, Diabetes
Your answer
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