Sunrise Family Medicine
4200 Wellness Drive, Suite 100, Portland, OR 97201
(503) 555-0388 · [email protected]
Patient Intake
Date: April 10, 2026
Patient Information
Full Name
Jordan Lee
Date of Birth
06/22/1988
Gender
Non-binary
Phone
(503) 555-0199
Email
[email protected]
SSN / ID
PAT-2026-0847
Address
420 Burnside Street, Apt 3, Portland, OR 97209
Marital Status
Single
Emergency Contact
Contact Name
Alex Rivera
Relationship
Partner
Phone
(503) 555-0184
Medical History
Primary Care Physician
Dr. Michael Torres
Physician Phone
(503) 555-0389
Current Medications
Sertraline 50mg daily, Vitamin D 2000 IU daily
Allergies
Penicillin (rash), Shellfish (anaphylaxis)
Prior Surgeries / Conditions
Generalized anxiety disorder, seasonal allergies
Insurance Information
Primary Insurance
Insurance Provider
BlueCross BlueShield of Oregon
Policy Number
BCB-849201847
Group Number
GRP-TECH-500
Policyholder
Jordan Lee
Consent & Authorization
I authorize Sunrise Family Medicine to provide treatment and release medical information as necessary for insurance billing. I understand my financial responsibility for any charges not covered by insurance.
Patient / Guardian Signature · Date
Staff Verification · Date
Sunrise Family Medicine · Patient Intake Form · Confidential