Health Insurance Intake Form
This is the Intake Form for a Medical Insurance Patient, who is relying on medical insurance for the compensation of treatment.
First Name *
Please type in your first name
Your answer
Last Name *
Please type in your last name
Your answer
Date of Birth *
Please use the formate MM/DD/YYY
MM
/
DD
/
YYYY
Gender *
Email
email will only be used for appointment confirmation, we will not contact you through email for any health or medical record.
Your answer
Address *
Example: 12345 43th Dr. SE
Your answer
City *
Full city name
Your answer
State *
Your answer
Zip Code *
5 digits
Your answer
Cell Phone *
123-456-789
Your answer
Home Phone
123-456-789
Your answer
Occupation
Example: Teacher
Your answer
Emergency Contact *
please type in the full name
Your answer
Emergency Contact Phone Number *
123-456-789
Your answer
How did you find us? *
Referring Clinic *
Please select your referring clinic from the list, or select 'Other' and type the full name of your clinic. If you were not referred to us, please select 'none'
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