Burns | Fortes Consulting: New Patient Intake Form

New Patient Intake Form

Burns | Fortes Consulting LLC
Todays Date:*

MonthDayYear
Date
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:*

SingleMarriedDivorcedSeperatedOther
Date of Birth:*

MonthDayYear
Date
Gender Identity:*

MaleFemaleTransgenderOther
Employer:
Emergency Contact:
Phone:

Area CodePhone Number
Primary Care Physician:
Date Last Seen:

MonthDayYear
Date
Current Medications:
Insurance Provider:*
Insurance Number:*
Prior Authorization:*

YesNo
Patient Name (If different from above):
Relationship:

SelfOther
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:*

Clear
Today's Date:*

MonthDayYear
Date
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: