Get Pentz Health Services Llc Dba Nevy Health New Patient Intake Form

Filling out the Pentz Health Services LLC dba Nevy Health New Patient Intake Form online is an important step in ensuring your health and wellness needs are met. This guide will provide clear and supportive instructions to help you complete the form effectively and accurately.

Follow the steps to complete the form seamlessly.

1. Press the ‘Get Form’ button to obtain the form and open it in your chosen digital editor.
2. Begin by entering your full name in the designated fields, starting with your last name followed by your first name. Ensure that the name is accurate as it will be used for your medical records.
3. Provide your mailing address, including the city, state, and zip code. Double-check for any typos to ensure effective communication.
4. Enter your primary phone number, ensuring to indicate whether it is a cell, home, or work number. Additionally, fill in your alternate phone number, if applicable.
5. Select your cell phone provider from the provided options.
6. Fill in your email address for future communication regarding appointments and health information.
7. Indicate your date of birth and gender by selecting the appropriate options.
8. Provide your social security number and select your marital status from the available options.
9. If applicable, indicate whether you have children and how many.
10. Enter your current occupation and employer information.
11. Provide the name and phone number of your primary care doctor. If you do not have one, check the option indicating this.
12. Answer the question regarding the possibility of pregnancy if applicable.
13. Indicate how you heard about the clinic.
14. Complete the emergency contact section with the full name, relationship, and primary phone number.
15. If your visit is due to an accident, indicate yes or no and provide details on the type of accident.
16. Fill in your payment method by circling the option that applies—self-pay, health insurance, auto insurance, lawyer, or worker’s compensation.
17. Provide the insurance provider name, policy ID, and the primary insured’s details.
18. If applicable, complete the secondary insurance section.
19. Indicate any specific interests related to your visit by circling the applicable options.
20. Use the body diagram to indicate where you are experiencing symptoms, marking them clearly.
21. Answer additional questions regarding the symptoms, including quality, frequency, and any previous health issues.
22. Complete the medications and allergies section, providing detailed information as required.
23. Fill in the family history section with the necessary information regarding health and causes of death.
24. Indicate any significant problems in your health history as prompted in the subsequent sections.
25. Review all information for accuracy before signing the form.
26. Save changes to the document, then download or print a copy for your records. If necessary, share the completed form with your healthcare provider.

Complete your paperwork online today to ensure your visit goes smoothly!