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
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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 MessageEmailTelephone 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

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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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