• Welcome to Main Street Physicians

    Patient Intake Form

  • Personal Information

  • Date of Birth (DOB)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is your gender identity?*
  • Marital Status (Please Check One)*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Ethnic Origin (Check One)*

  • Emergency Contact Information

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Guarantor Information

    Financially Responsible Party
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Browse Files
    Drag and drop files here
    Choose a file
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  • Release Information

    I authorize the release of any information concerning my health care advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor I understand that I am responsible for any amount not covered by my insurance I request that payment of authorized Medicare benefits be made to my physician. 

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Policy on Missed or Cancelled Appointments

  • Unfortunately, too many of our patients are missing appointments repeatedly. When this occurs, it leaves fewer appointments available for patients who need care. We realize that the occassional missed appointment may be unavoidable, but this should be rare.

    Any appointment missed, or cancelled without 24 hours notification will be considered a "No Show". The charge per "No Show" is $25.00. After a total of three "No Show" appointments within a short interval of time, the patient will be regretfully discharged from our practice, and from our care. No further appointments will be scheduled, due to the unwillingness to follow our physician's plan of health care.

     

    Thank you for your understanding and cooperation.

     

     

    I have read and understand the above policy.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Acknowledgement of Notice of Privacy Practices

  • My signature acknowledges my receipt of the Notice of Privacy Practices from Agape Primary Care.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Authorization for Release of Information

    To be filled out if there is more than one entity authorized.
  • Date of Birth (DOB)
     / /
    2 digit month, 2 digit day, 4 digit year

  • Agape Primary Care is authorized to release protected health information concerning the above named patient to the entities listed below. The purpose is to inform the patient of designee of health matters, as per the patient instructions.

  • Entities authorized to recieve information:

  • Format: (000) 000-0000.

  • Description of information to be released.

  • (Check each item that can be given to person or entity authorized)

  • Rights of Patient: I understand that I have the right to revoke the authorization at any time and that I have the right to inspect a copy of the protected health information to be disclosed as described in the Notice of Privacy Practices previously provided to me. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this information may be subject to re-disclosure by the recipient and may no longer be protected by federal state law.

    I understand that I have the right to refuse to sign this authorization and that my treatment will be conditioned or signing. This authorization shall be in effect until revoked by patient.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Patient Consent for Electronic Prescribing (E-Prescribing)

  • I have been made aware and understand that the medical practices and office may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my providers and my pharmacy. I have been informed and understand that my providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my providers to see this protected health information.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Internal Medicine Health History Questionnaire

  • Your answers on this form will help your health care provider better understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. If you cannot remember specific details, please approximate them. Add any notes you think are important. ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

  • ALLERGIES (List anything you are allergic to [medications, food, bee stings, etc.] and how each affects you.)
    Rows

  • Are you interested in having your prescriptions mailed to your home?

    Main Street Physicians partners with SC Home Rx to provide you with a simple & excellent pharmacy experience. SC Home Rx can deliver your prescriptions every month at the same time and you never have to wait in line again at a traditional pharmacy. Talk to your provider today about setting up SC Home Rx as your preferred pharmacy.

  • Medications

  • (Please list all the medications you are taking. Include prescribed drugs and over-the-counter drugs, such as vitamins and inhalers.)
    Rows

  • Immunization History

  • Immunizations & Most Recent Date:
    Rows

  • (Women Only) Obstetric and Gynecological History

  • Rows
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  • Fill out information below if you answered "Yes".

    Otherwise, skip to "Past Medical History".

  • Current sexual partner is:
  • Do you use condoms?
  • Are you interested in being screened for STDs?

  • Past Medical History

  • (Please check all that apply.)

  • Past Surgical History

  • (Please list any surgeries below.)
    Rows

  • Family Health History

  • Rows

  • Social History

  • Alcohol
    Rows
  • Caffeine
    Rows
  • Drugs
    Rows
  • Education
    Rows
  • Exercise Level
    Rows
  • Tobacco Usage
    Rows
  • If you answered "Yes" to either question above, please fill out below:
    Rows

  • Review of Systems

    Please check all that apply:
  • Allergic/Immunologic
  • Cardiovascular
  • Constitutional
  • Eyes
  • Ears/Nose/Mouth/Throat
  • Endocrine
  • Gastrointestinal
  • Genitourinary
  • Hematologic/Lymphatic
  • Integumentary (Skin)
  • Musculoskeletal
  • Neurological
  • Psychiatric
  • Respiratory
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Authorization for the Use and Disclosure of Protected Health Information

  • I hereby authorize Main Street Physicians/SC House Calls to use or disclose my protected health information as described below. I understand that the information I authorize a person/facility to recieve my be re-disclosed and no longer protected by state and federal regulations.

  • Date of Birth (DOB)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Name of Person/Facility Authorized to RELEASE the Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Name of Person/Facility Authorized to RECEIVE the Information

  • Name of Person/Facility Authorized to recieve the information: 

    Main Street Physicians/SC House Calls

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Dates of Treatment
    Rows

  • Information to be Used/Disclosed

    (Please check all that apply):

  • I understand that in the event I was treated for drug or alcohol abuse, psychiatric condition, and/or communicable diseases including HIV/AIDS this information will be included as part of my medical record to the above-named person/facility.

    LTC Health Solutions may not condition treatment, payment, enrollment or eligibility for benefits on signing this authorization.

    This authorization is subject to cancellation/revocation at any time, by the patient or legally qualified representative, provided that the cancellation is made in writing except to the extent that:

    1. The facility has already acted on your request prior to receiving the request to cancel the authorization; or
    2. If the authorization was given to release records to your insurance company in order to obtain insurance coverage.

    This authorization will expire in 90 days unless otherwise stated.

  • Expiration Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: