The How Clinic Intake Form

Patient Information and History

Insurance Information: While most of our services are not able to be billed to insurance. We ask for your insurance details to have on file for forwarding to outside labs or imaging centers.

Insurance Information

Please add images of ALL of your insurance cards and a photo ID (front and back)

Or

You may also take photos of you cards now:

If yes, add these images below

Driver's License or ID

Payment Policies

Our front office will collect and store an encrypted format of your credit card in your patient portal, Onpatient.

These fees may also apply:

Prescription Policy

Please do not wait until your last pill to call for a refill. There is a 72 hour turn around for prescription refills. If you have not seen the Physician in six months, the prescription will be denied. Assignment of benefits are payable to the doctors.

Important History and Information

Cardiovascular Wellness

Based on your medical history and risk factors, your healthcare provider may recommend a simple, non-invasive test to determine your risk for cardiovascular related diseases. This diagnostic test (plethysmography) is an excellent screening tool that will provide valuable information for the early detection of atherosclerosis or related diseases.

I have received a copy of the HIPAA Notice of Privacy Practices.

Patient Information and History

Insurance Information: While most of our services are not able to be billed to insurance. We ask for your insurance details to have on file for forwarding to outside labs or imaging centers.

Insurance Information

Or

Payment Policies

Prescription Policy

Important History and Information

Family History

Personal History

Cardiovascular Wellness