LaVidaCare Patient Intake Form

Patient Intake Form

LaVida Care - SFCHC HIV Prevention Program
Please complete each section of the form below, review our Notice of Privacy Practices, and electornially sign at the bottom of the page before submitting.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Date
Email
example@example.com
Phone Number*
Please enter a valid phone number
Sex*

MaleFemaleIntersex
Gender Identity*

MaleFemaleTransgender MaleTransgender FemaleOtherDo not wish to disclose
Pronouns*

He/Him/HisSher/Her/HersThey/Them/TheirsOther

EMERGENCY CONTACT
If you would prefer to not have an emergency contact on file with us, please check the box below. Otherwise, please enter your emergency contact information into the spaces provided.
Decline Emergency Contact

I decline to have an emergency contact on file
Contact Name

First NameLast Name
Relationship
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.

PRIMARY CARE PROVIDER
Please indicate below whether you currently have a primary care provider and enter their contact information.
Primary Care Provider Status*

Yes, I currently DO have a Primary Care ProviderNo, I currently DO NOT have a Primary Care Provider
Primary Care Provider Name

First NameLast Name
Clinic Name
Clinic City
Clinic Phone
Please enter a valid phone number

INSURANCE INFORMATION
Please indicate below whether you currently have a medical insurance and enter their contact information.
Insurance Status*

Yes, I currently DO have Medical InsuranceNo, I currently DO NOT have Medical Insurance and would like to request for a Patient Assistance Program
If you answered "yes" to the question above, please include the name of your insurance provider and upload a copy of your insurance card (front and back).
Insurance Provider
Insurance Card (Front)
Insurance Card (Back)

PATIENT SIGNATURE
PLEASE NOTE: This form requires your electronic signature. Use your mouse, finger, or stylus to sign in the space provided.

By signing below, I understand and acknowledge the above information and consent to and agree to proceed with any treatment proposed. I acknowledge that I have been advised of my financial obligations to San Fernando Community Health Center including copays, deductibles and any anticipated denials for products furnished by the clinic. I also certify that I was given an opportunity to ask questions and all of my questions have been satisfactorily answered.
Date*

MonthDayYear
Date
Signature*

Clear
Please verify that you are human*
Should be Empty: