New Patient Intake Form
Contact Information
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Email
example@example.com
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Gender Identity
Male
Female
Other
Social Security #
Format: 000-00-0000.
Marital Status
Single
Married
Widowed
Divorced
Emergency Contact
Emergency Contact Name
Phone #
Format: (000) 000-0000.
Relationship to you
Pharmacy Information
Pharmacy Name
Pharmacy Phone Number
Format: (000) 000-0000.
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Policy Information
Primary Insurance Company
Member ID #
Group #
Provider Customer Service Phone # (found on back ofcard)
Format: (000) 000-0000.
Policy Holder (if not self)
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Policy Holder's Relationship to you
Past Medical History
Please list any previous surgeries.
Drug Allergies
Drugs and Reactions
Current Prescription Medications
Current Prescription Medications
Current Over-the-Counter Medications/Supplements
Current Over-the-Counter Medications/Supplements
Please briefly describe the recent concern, which have led to your seeking for an evaluation/treatment
What are your 3 biggest stressors at this time?
Medical Insurance
*
I authorize the medical insurance company to pay directly for the above physician's services. I, however, understand that the person who signs below is responsible for all of my fees, including any fees not paid by the insurance company.
Release of Information to Insurance Provider
*
I authorize Insyte Psychiatric LLC to release/receive verbal or written information about me to/from the medical insurance company and the referring physician. This authorization will end if I give written instructions to Insyte Psychiatric LLC to that effect, which I may do at any time.
Financial Responsibility
*
I understand and agree that the undersigned is responsible for the respective patient's fees to Insyte Psychiatric LLC. Which will include fees not paid by medical insurance, account balances not paid when due, collection and court costs, processing fees, cancellation and “No Show” fee for follow-up appointments is $200 and the fee for missed new patient appointments is $400. Fees for services are to be paid at the time services are rendered. By signing, I agree to take on full financial responsibility for the patient in question, whether that be myself or a family member.
Patient signature
Submit
Should be Empty: