Online Intake Form Intake form Patient Information Patient Full Legal Name * Date of Birth * Social Security Number * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone Number * Email * Whom may we thank for this referral? Do you have a scheduled appointment? * Yes No, I need an appointment Date of scheduled appointment * Medical Information Chief Complaint/Reason For Visit List of Allergies (medications, food, etc.) List Any Medications You Are Currently Taking List Any Conditions We Should Know About Insurance Information Only fill out if we did not take a copy of your insurance card. Primary Insurance * ID Number * Name of Employer Group Number Name of the Subscriber Social Security Number Subscriber Date of Birth Front and Back of Insurance card/ Referrals Drop a file here or click to upload Choose File Maximum upload size: 67.11MB I understand that I am financially responsible for all charges that are not covered by insurance benefits. I also authorize the release for any medical information to process claims. Read Privacy Policy Terms (required) * I have thoroughly read the Office/Privacy Policy, agree to its terms and agree to the fee agreement listed on the final page. Signature * Date Submit
