Schedule your appointment

Patient Intake Form

If you’d like to complete the patient intake form in advance, you can do so using the form!

Prefer a different option? Download and print the PDF at the bottom of the page, or simply fill it out when you arrive at the clinic for your appointment.

Patient Intake Form

Privacy
Patient Info
Responsible Party
Medical Info
Pharmacy
Insurance

Privacy Notice

Privacy Notice: Your personal health information is protected under HIPAA. We collect and use your information solely for providing medical care, billing, and administrative purposes. Your data is securely stored and will not be shared with unauthorized parties without your consent.

I have read and agree to the Privacy Notice

I hereby consent to receive medical treatment and authorize the use of my Protected Health Information (PHI) for the purposes of my care, billing, and administrative operations as described in the Privacy Notice.

Preferred Location

Patient Intake Information

First Name

Last Name

Prefered Name / Nickname

Gender

Date of Birth

Home Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Employer

Occupation

SSN (If ins. requires)

Responsible Party (if patient is a minor)

Parent/Guardian Full Name

Relationship to Patient

Date of Birth

Primary Phone #

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

List All Current Medications & Dose

Including Over the Counter & Suppliments

Allergies

Primary Care Physician (PCP) Information

Physician Name

Phone #

By checking this box, I agree to have my records or diagnosis information shared with my physician.

Pharmacy Information

Pharmacy Name

Pharmacy Phone #

Pharmacy Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Insurance Information

Insurance Carrier

Member Name

Member ID

Group Number

Policy Number/Identification Number

If you would like to download a PDF version to bring into our office, click here.

Schedule your appointment

Patient Intake Form

Privacy Notice

Patient Intake Information

Responsible Party (if patient is a minor)

List All Current Medications & Dose

Allergies

Primary Care Physician (PCP) Information

Pharmacy Information

Insurance Information

In need of 24/7 emergency care services?

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Call Now: (563) 263-2020

24/7 Emergency Care

Call Now: (563) 263-2020

24/7 Emergency Care

Call Now: (563) 263-2020