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
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SSN
XXX-XX-XXXX
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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
Your answer
Street address
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City
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State
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Zip
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Patient Relationship to Guarantor
Self, Spouse, Child or Other
Your answer
Guarantor's name (if other than self)
Your answer
Guarantor's date of birth (if other than self)
Your answer
Guarantor's address (if different from patient's)
Your answer
Guarantor's primary phone number (if other than self)
Your answer
DEMOGRAPHICS
Ethnicity
Hispanic/Latino, Not Hispanic, etc
Your answer
Race
White, Black, Asian, American Indian, etc
Your answer
Language
Your answer
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
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Please share how you heard about us.
Facebook, Friend, Google Search, etc.
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Payment Preference
Insurance or Self pay (If paid with cash/credit/debit in full at time of service, a 50% discount is applied to the total bill)
Your answer
INSURANCE INFORMATION
Primary Insurance Name
We are currently not accepting United, Humana or certain Medicare Advantage plans. We are working on this every day. Follow us on Facebook to get updates on when these are approved. If you have a secondary insurance, please notify the provider at the time of visit.
Your answer
Plan Name & Type
HMO, PPO, etc
Your answer
Insurance ID
Your answer
Group ID
Your answer
Effective From
MM/DD/YYYY
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Effective To
MM/DD/YYYY
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Copay $ Amount
Your answer
Relation to insured
Self/Spouse/Child/Other
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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
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
Very Mild/Mild/Moderate/Severe
Your answer
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
Your answer
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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