The How Clinic Intake Form

  • Patient Information and History

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  • What is your Gender?*

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  • I am coming to see:
  • Referred to this office by*

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  • Driver's License or ID

  • 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.

  • Do you have health insurance?*
  • Are you the primary insured?*
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  • Insurance Information

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

    You may also take photos of you cards now:
  • Do you have a secondary insurance?*

  • If yes, add these images below
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  • 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.
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  • Important History and Information

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  • Is visit related to work or auto injury?
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  • Are you sensitive to Latex?*
  • Are you sensitive to Adhesives?*
  • Are you sensitive to Iodine/Seafood?*
  • Are you sensitive to any medicines?*
  • Have you had any problems with anesthesia?*
  • Have you recently been on any steroids?*

  • Personal History

  • Past medical conditions? If yes, please choose all that apply below.*
  • Cardiovascular Conditions

  • Respiratory Conditions

  • Gynecological Conditions

  • Endocrine and Metabolic Conditions

  • Gastrointestinal Conditions

  • Neurological Conditions

  • Cancer:

  • Other Conditions

  • Past surgical history*

  • Social History
  • How often do you consume alcohol?*
  • Do you currently (within the last week) use tobacco products?
  • Check the conditions that apply to you*

  • Check all Symptoms of Medical Conditions That Are Present*

  • Family History

  • Select all that apply

  • Family History of Breast Cancer?
  • Family History of Colon Cancer?
  • Family History of Melanoma?
  • Family History of Other Cancers?
  • Family History of Diabetes?
  • Family History of Heart Disease?
  • Family History of Hypertension?
  • Are you currently using any type of hormone replacement?
  • Email newsletter: Do we have your permission to send emails regarding new services and updates?*
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  • give my express permission to The How Clinic and John How, M.D. to obtain, and access to all of my medical records (with any exceptions or limitations listed in next section). I understand that my personal and medical information may be stored on a password protected secure cloud service.

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