New Patient Intake Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Address (if different) Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Gender * ... Male Female Phone * (###) ### #### Email Notification Preference (can choose multiple): * ... Text Email Text & Email None Allergies/Medical Conditions Allergies and Reactions (ex. penicillin-rash): * Type "None" if no allergies Medical Conditions (check all that apply) * Hypertension (I10) Type 2 Diabetes (E11.9) Type 1 Diabetes (E10.9) Hypothyroidism (E03.9) Hyperlipidemia (E78.5) Anxiety (F41.1) Depression (F32.9) Acid Reflux (K20.9) None Other conditions not listed: Insurance Information Insurance Type * ... Medicare Medicaid Commercial No Insurance Rx ID: BIN: PCN: Group: Customer Service Phone Number: Current Medicaitons Prescriptions Medications/Supplements: * Type "None" if not taking any prescription medication or supplements By electronically signing below, I acknowledge that I am either the patient listed above or an authorized caretaker of the patient listed above and that the information listed is complete and accurate to the best of my knowledge. I am aware that incomplete answers could negatively affect the patient listed above. * E-Signature Date * MM DD YYYY Thank you!
