Hicks Group Wellness Center Client Intake Form

Hicks Group Wellness Center Client Intake Form

| 116 Millburn Avenue, Ste 104 | Millburn, NJ 07041
Patient Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Emergency Contact Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Relationship
Insurance Information
Name of Insurance
Subscriber first and last name (list as "self" if the patient is the subscriber)
Subscriber Date of Birth

Month Day Year
Date
Subscriber Relationship to Patient
Policy Number
Group Number
Secondary Insurance Policy Number (if applicable)
What is the PROVIDER'S NUMBER on the Back of your card? (MEMBER SERVICES is acceptable)? *

Area Code Phone Number
ASK and WRITE: HOW DID YOU HEAR ABOUT US? WRITE DOWN TENTATIVE APPT
Additional comments or concerns
APPOINTMENT AGREEMENT: Do you agree and understand that this office has Hybrid Hours (2 weeks face-to-face and 2 weeks TeleHealth)? And that your appointment is set to the specific day and time as we discussed (say day and time and weekly if weekly or biweekly if biweekly)? That you must use your health plan as we do not accept EAP? And that You must fill out the two Consent Forms and the fee agreement before your first appointment. Lastly, you must also submit a form of ID? Do you agree and understand? *
Date

Month Day Year
Date
Should be Empty:

Hicks Group Wellness Center Client Intake Form

Emergency Contact Information

Insurance Information