{{ practice_name }}
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Patient Intake
Form
Date ____ / ____ / ____
Chart # ____________
For office use only
Reason for today's visit / chief complaint
1

Patient Information

Please print clearly
2

Emergency Contact & Insurance

3

Medical History

Check any you have or have had
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4

Current Medications & Allergies

Medication / supplement
Dose
How often
Prescribing doctor
5

Consent & Acknowledgement

I certify that the information above is true and complete to the best of my knowledge. I acknowledge that I have received {{ practice_name_consent }}'s Notice of Privacy Practices describing how my protected health information may be used and disclosed under HIPAA, and I consent to evaluation and treatment by the practice's clinicians.

I understand I am financially responsible for any balance not covered by my insurance, and I authorize the practice to release information to my insurer as needed to process claims.

I have read, understand, and agree to the statements above.
Patient signature
Printed name
Date
If the patient is a minor: parent / guardian signature ___________________________ Printed name __________________ Date ________
{{ practice_name_foot }} · Confidential patient record {{ form_ref }}