Patient Intake Form

Name*

Birth Date*

Social Security Number

Address*

Street Address Line 2

Email*

YesNo

SingleMarriedWidowedDivorced

MaleFemaleNon-Binary

Home Phone

Format: (000) 000-0000.

Mobile Phone*

Format: (000) 000-0000.

YesNo

Patient Employed By

In case of emergency, who should be notified?*

Phone*

Format: (000) 000-0000.

Subscriber Name

Birth Date

Relationship to Patient

Social Security Number

Address (if different from patient)

Street Address Line 2

Subscriber Employed By

Insurance Company

Insurance ID #

Group #

YesNo

Subscriber Name

Birth Date

Relationship to Patient

Address (if different from patient)

Street Address Line 2

Subscriber Employed By

Business Phone

Format: (000) 000-0000.

Insurance Company

Insurance ID #

I authorize treatment and agree to pay all fees for such treatment. I hereby authorize my insurance benefits to be paid directly to the provider of service, and I am financially responsible for non-covered services, copays, deductibles, and coinsurance. I also authorize release of any information required. I agree that I will not withhold or delay payment if my insurance company denies payment of any of my charges. In the event it should become necessary to place my account with a collection agency on an unpaid balance due for services rendered to me or my family, I/we agree to pay collections fees, and should legal action be filed, reasonable attorney fees, filing costs, and any other costs the court determines proper.

Signature*

Date

Q

K

Bundle

PATIENT INTAKE FORM

Patient Information

Primary Insurance

Additional Insurance

Authorization and Financial Agreement