New Patient Intake

Sex *

Used for clinical records and laboratory reference ranges.

Primary phone number *

Alternate phone number

Primary phone type *

Mobile Home Work

Can we leave voicemails containing medical/billing information at this number? *

Yes No

Can we send automated text appointment reminders to this number? *

Yes No

Text reminders are typically sent to mobile numbers.

Alternate phone type

Mobile Home Work

Can we leave voicemails containing medical/billing information at this number?

Yes No

Preferred contact method

Emergency contact name & phone

Parent / Legal Guardian Information

Required for patients under 18 years old.

Full name of parent or legal guardian *

First name *

Last name *

Relationship to patient *

Mother Father Step-Parent Foster Parent Legal Guardian Other

Do you have legal custody and the authority to consent to medical/psychiatric treatment for this minor?

Yes No

Is the patient currently in State Custody or under State/Corporate Guardianship? *

Yes No

Name of authorized guardian / agency *

Designated case manager / representative name *

First name *

Last name *

Relationship / authority type *

State-Appointed Guardian Corporate/Agency Guardian Biological Parent with Rights Court-Appointed Public Guardian Other

Do you have the legal authority to sign and consent to medical/psychiatric treatment for this patient?

Yes No

Note: A copy of the formal Court Order or Guardianship Decree must be provided to our office prior to or during the initial intake appointment.