Patient Intake Appointment Pre-screening Form

Patient Intake Appointment Pre-screening Form
Please complete this form prior to your medical appointment to help us prepare for your visit.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name and Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Schedule Your Appointment
Do you have any of the following medical conditions? (Select all that apply)
Other
Please list any allergies (medications, foods, environmental, etc.)
Please list any medications you are currently taking
Briefly describe the reason for your visit or current symptoms
Do you have health insurance?
Please provide your insurance provider name (if applicable)
Should be Empty: