Integr8 Health Express Intake
Welcome back, and thank you for taking a couple minutes to complete our intake and consent forms. We look forward to the opportunity to serve you. The information you submit in this HIPAA-secure form is protected health information and will be used only by this office unless you provide a written release. **Please do not use use your auto-fill function, it creates a problem for some users that prevents advancing and completing the form**

Please complete this consent form only if the office has explicitly approved you for an express certification renewal visit.
Email *
First name *
Last name *
Date of Birth *
Phone Number *
Complete Mailing Address *
What is your gender *
Primary phone *
Secondary phone
Emergency contact name, relationship, and phone number *
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