New Patient Intake form

1
Patient's Name* This field is required.
First Name
Last Name
2
Patient's Date of Birth* This field is required.
Date
Month
Day
Year
3
If patient is a minor, Parent's Name
First Name
Last Name
4
Email (To set up your patient portal)* This field is required.
example@example.com
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
7
Gender Identity
Female
Male
Transgender Female
Transgender Male
Genderfluid
Non-Binary or Gender Neutral
8
Assigned Gender at Birth
Male
Female
9
Insurance Company & Plan NameWe take Pacific Source, First Choice, Medicaid/OHP, Pacific Source Medicare, United, Regence, Blue Cross Blue Shield, MODA (Not 360 plans), Tricare, HMA, Health Comp, & Providence.
10
Insurance Member ID & Group Number
11
Please take a Photo of your Insurance Card
12
What do you need to be seen for?
0/200
Huge
Large
Normal
Small
Ok
Ok
13
Which provider would you like to see?Please check appropriate box(es):
Soonest Available Provider
Whoever is best with my health needs
Rachel Query, NP (Primary Care, Pediatrics, & Integrative Care)
Marie Mency, NP (Primary Care, Pediatrics, & Women's Health)
Jeremy Brodhead, NP (Urgent Issues or Illnesses, Sport Medicine/Injuries, Men's Health, & Limited Primary Care Availability)
Havilah Brodhead, NP (Primary Care with Functional Medicine)
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What type of appointment are you wanting?OHP/Medicaid/Medicare are not eligible for Functional Medicine
Primary Care with an Integrative/Holistic focus
Primary Care for multiple complex health conditions
Same Day / Urgent Visit
I just want to get established with a PCP for a health check up & in case I have problems in the future.
Primary care with integrated Functional Medicine with Havilah Brodhead NP.
Men's Health
Sports Medicine
Pediatrics
Transgender Hormone Care
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Havilah Brodhead has trained in Functional Medicine and incorporates this into her primary care. Some patients would especially benefit from this type of root cause medicine.
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We want to make sure you are a good fit for Hearthside Medicine Family Care.Please provide some history about your concerns.
What health concerns are you wanting addressed?
What have you already tried?
What labs or imaging or studies you have already done?
What specialists have you already seen?
What other providers Traditional, Holistic, & Functional have you already seen?
17
Thank you for submitting a brief overview of your concerns and history. We will review your case and let you know within 5 days if we can get you scheduled with Havilah Brodhead.

Marie Mency FNP, Rachel Query FNP, and Jeremy Brodhead FNP are also all offering integrative primary care and are accepting new patients as well. If we are unable to accomodate you into Havilah's care we always encourage you to establish with our other members of our incredible team.
18
Insurance Billing: Rates vary widely depending upon your medical benefits & plan. It is the patient's responsibility to understand coverage, including deductible and in-network status. Patient responsibility is determined by patient's insurance plan. Hearthside Medicine billing rate is equivalent or less then local institutions, however we bill according to time and services provided.* This field is required.Please initial below that you agree and understand these terms.
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Once your form is submitted, we will email you instructions to create your patient portal account within 2 business days. You must complete the new patient intake forms via your portal once registered in order to be scheduled. We require a credit card on file in the event of late cancels or reschedules, which will incur a $50 fee.* This field is required.Please initial below that you agree and understand these terms.
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Thank you for choosing Hearthside Medicine Family Care!
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