Burns | Fortes Consulting: New Patient Intake Form

New Patient Intake Form

Burns | Fortes Consulting LLC
Todays Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Source:
Client Concern:
Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Marital Status:

Other
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender Identity:

Other
Employer:
Emergency Contact:
Phone:

Area CodePhone Number
Primary Care Physician:
Date Last Seen:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Medications:
Insurance Provider:
Insurance Number:
Prior Authorization:
Patient Name (If different from above):
Relationship:

Other
Address (If different from above):

Street Address

Street Address Line 2

CityState

Zip Code
Patients Employer:
Payee responsibility for no show/late cancellation policy. We work closely with your insurance company to ensure payment for our services. In the event your insurance company rejects the claims (deductible, ineligibility, etc.) you are responsible for the payment for services rendered. Please be advised that you must provide 24-hour notice for cancellation.

Failure to do so may result in your being charged for the missed appointment.
Signature:
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby give permission to furnish information, including a psychiatric diagnosis to my insurance company. In consideration of services rendered, or to be rendered, I hereby assign and transfer to: any benefits.
Should be Empty: