Primary Care Intake

Primary Care Intake
Legal Name*

First NameMiddle NameLast Name
Gender*

MaleFemaleGender Non ConformingChoose not to Disclose
Date of Birth*

MonthDayYear
Date
Insurance Number
Insurance Type
Name of insurance
Referred Patient is an Adult?*

YesNo
Parent/Guardian Name

First NameLast Name
Parent/Guardian Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Alternative Phone Number

Area CodePhone Number
Emergency Phone Number

Area CodePhone Number
Email
example@example.com
Reason for Referral
Should be Empty: