Patient Intake Checklist - EN

Shalom Health Care Center

PROVIDING QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE, AND ACCESSIBLE FOR ALL IN OUR COMMUNITY
Shalom Health Care Center

PROVIDING QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE, AND ACCESSIBLE FOR ALL IN OUR COMMUNITY
Patient Name
Date

Month Day Year
PARENT/LEGAL GUARDIAN

PATIENT INTAKE CHECKLIST
1.	I have received a copy of the notices listed below. My initials by each notice indicate that I have received that notice and my questions have been answered. As a patient of Shalom Health Care Center, I agree to the policies and procedures in those notices.

Patient/Provider Agreement
Missed Appointment (No-Show) Policy
Expected Payments Policy
Patient Portal Accept Decline
Email: Email
Patient Consent for Treatment and Notification of Use and Disclosure of Protected Health Information
Notice of Privacy Practices

2.	I understand Shalom Health Care Center utilizes the following methods to contact me regarding my care and/or leave messages regarding my care via the following method(s):

Text Message Email Telephone Call

3.	I have completed the “Patient Registration Form” and (if applicable) “Patient Consent for Treatment of a Minor and/or Release of Information to Others” to the best of my ability and I request that information on those forms be included in my/my child’s health records.
4.	I give my consent to be examined and/or treated by Shalom Health Care Center’s health care providers. I understand and agree that any in-depth examination and/or procedure will be explained to me before I give my consent.
5.	All documents, policies, and procedures included in the Shalom Health Care Center intake process have been explained to me, and I understand that if I have any questions, I may ask a Shalom staff member at any time.

Signature of Patient or Parent/Legal Guardian *

Clear
Date

Month Day Year
The Center receives federal funding from Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect tocertain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.
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