Get Patient Intake Form

Completing a patient intake form online is an important step in receiving the appropriate medical care. This guide will provide you with a clear, step-by-step approach to filling out the Patient Intake Form efficiently and accurately.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Patient Intake Form and open it in your preferred web browser.
2. Begin by filling out your personal information in the designated fields. This includes your last name, first name, middle initial, suffix, date of birth, age, and social security number.
3. Provide your complete address, including city, state, and zip code. Ensure you also include your home and mobile telephone numbers.
4. Indicate your marital status by selecting the relevant option (single, married, widow/widower, etc.). If applicable, include your spouse or partner’s name.
5. Identify an emergency contact, including their relationship to you and their contact numbers.
6. For the ethnicity section, check all that apply to you from the provided options.
7. Enter your primary and secondary insurance details. This includes the insured name, date of birth, and social security number for each plan.
8. Fill out the physician information section. Identify your primary care physician and any other specialists you may be seeing, including their contact information.
9. In the symptom description area, provide detailed information about your symptoms, including the location of pain and duration.
10. Include your social history, noting current or previous occupation, household situation, and habits such as smoking or drinking.
11. List all current and previous medical problems and operations in the designated sections.
12. Complete the review of systems section by checking all that apply to your health history.
13. Input details about your current medications, along with reasons for taking them, dosages, and frequencies.
14. Finally, indicate any known allergies and reactions. Use the options to specify allergies to medications, latex, or iodine/betadine.
15. Once all sections are completed, review your information for accuracy. You can then save your changes, download the completed form, print it, or share it as required.

Start filling out your Patient Intake Form online today to ensure a smooth process for your medical appointment.