Patient Information

Patient Information

Demographics & Medical History
Date*

MonthDayYear
Today's Date
Patient Demographics
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
For our SMS privacy policy, please visit https://rootcauses.com/sms-privacy-policy/

Patients may rescind text and email permissions at any time but updating their contact preferences within the electronic health record, or by emailing sa.admin@rootcauses.com.
Authorization to Receive Texts and Emails*

Authorized
Gender at Birth*
Marital Status*
Occupation*
How did you hear about Root Causes?*
Emergency Contacts
Emergency Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Patient*
Parents Names & Contact Information*
If patient is a minor child, please include above the names and phone numbers of all parents authorized to request medical treatment on the child's behalf and access to their health record. If you are not a minor child, please type "N/A."
Pharmacy Preference
Pharmacy Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Fax Number*
Please enter a valid phone number.
Health Insurance

(For use with some laboratory testing and radiology orders only. Please remember to upload a copy of both sides of all insurance cards in the patient portal, Cerbo.)
Do you have health insurance?*

YesNo
Insurance Carrier Name*
Member ID*
Group Number*
Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Phone:*
This is located on the back of your member card.

Patient Narrative*
Please provide a brief personal medical history in your own words, starting with the last time you felt vibrantly healthy.

	Never	Within 1 Year	2-5 Years	Over 6 Years	Comments
Colon Hydrotherapy
Colonoscopy
Electrocardiogram (ECG/EKG)
Endoscopy
Physical
Sigmoidoscopy

	Brand	Medication Name	Dosage Amount (Strength in Mg)	Dosage Frequency	Ordering Doctor
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Patient Information

Patient Demographics

Emergency Contacts

Pharmacy Preference

Health Insurance

Medical History