Follow the steps to successfully complete your intake form.

1. Click ‘Get Form’ button to access the patient intake form and open it in your document editor.
2. Enter today's date and your account number in the designated fields at the top of the form.
3. Provide your personal details, including your name, birth date, and age. Complete your address, city, state, and zip code as well as your phone numbers, including cell and work numbers.
4. Fill in your email address. If you prefer not to share your email or do not have one, initial in the provided section.
5. Specify your preferred language, race, and ethnicity. Indicate your work status by circling one of the options provided.
6. Select your marital status by circling the appropriate option.
7. Complete the emergency contact section with the name, relationship, and phone number of a contact person.
8. Provide your primary care physician's details, including their name, address, and phone number. Repeat this for any referring physicians and specialists, including cardiologists and podiatrists.
9. Fill in your pharmacy information, including name, city, state, and phone number.
10. Complete the insurance information section with the details of your primary and secondary insurance, including copay amounts and policy holder's information. Indicate whether a referral is required and if it has been obtained.
11. Provide dialysis information if applicable, including dialysis type and access details.
12. Complete the medical history section by providing your height and weight and indicating any of the listed health conditions by circling 'yes' or 'no.'
13. Detail your surgical history, indicating if you have had any relevant procedures.
14. List any medications you are currently taking, including dosages and the frequency of use.
15. Indicate any allergies and adverse reactions to specific substances.
16. Review and acknowledge the HIPAA Privacy Notice and provide your signature along with the date.
17. Sign the consent to treat section and provide the date.
18. Fill in the disclosures section for family members or friends if you choose to allow information sharing.
19. Authorize communication via cellular phone and/or email by signing this section.
20. Finally, review your form for completeness, save your changes, and consider downloading, printing, or sharing it as necessary.

Complete your patient intake form online today to streamline your appointment process.