NEW Initial Intake Form

Patient Information and History
Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Social Security Number
Email *
example@example.com
Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
What is your Gender? *

Male Female Male to Female Female to Male Intersex Non-binary Prefer not to say
Spouse Name (if applies)

First Name Last Name
Spouse Phone Number (if applies)

Area Code Phone Number
Referred to this office by: *
Emergency Contact Not Living With You
Name
Emergency Contact Phone Number

Area Code Phone Number
Pharmacy (Name, address, phone if possible)
Insurance Information

Please upload photos of your insurance cards and a photo ID
Insurance Card (Front)
Insurance Card (Back)
Secondary Insurance Card (Front)
Secondary Insurance Card (Back)
Photo ID (Front)
Photo ID (Back)
Primary Insurance (If primary insured is NOT the patient, list souse or other information of primary insured below)

First Name Last Name
Insured Date of Birth

Month Day Year
Date
Insured Social Security Number
Insurance Company
ID #
Group #
Patient's Relation To Insured
Secondary Insurance Information (If secondary insured is NOT the patient or, list spouse or other information of secondary insured below.

First Name Last Name
Insured Date of Birth

Month Day Year
Date
Insured Social Security Number (If not the patient)
Insurance Company
ID #
Group #
Patient's Relation To Insured

Patient Information and History