Medical Scribe Patient Information Intake Form

Patient Full Name

First NameLast Name

Date of Birth

Date

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 CodeCountry

Appointment Date and Time

Date

Hour MinutesAM/PM Option

Reason for Visit

Current Symptoms or Concerns

Current Medications (List all current medications including dosages)

Allergies

Past Medical History (Select all that apply)

Primary Care Provider Name

Preferred Pharmacy Name and Location

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you authorize medical scribe documentation during your visit?