BHS Established Patient Intake Form

Established Patient Information
Warning: This form will time out if not completed in one sitting
Patient Name:*

First NameMiddel InitialLast Name
Date of birth*

MonthDayYear
Date
Sex*

MaleFemale
Social Security
Country*
Please select Country of Residence
Address*
Street
City*
State/ Province / Region
State*
Zip Code*
Permanent Address (if different from above)

Street Address

CityState

Zip Code
Country
Please select Country of Residence
Primary Phone Number*
Please include country code for non-U.S number
Secondary Phone Number
Please include country code for non-U.S number
E mail Address*
example@example.com
Referral source:*
Name of referring person:
Which Social Media?
What Keywords did you search?*
For example: "Hand Surgeon"
Do you have Workers Comp Insurance?
Workers Comp Insurance Company Name
Address for claims:
Adjuster name:
Phone Number

Area CodePhone Number
Do you have insurance?
Primary Insurance Company Name
Phone

Area CodePhone Number
Policy Number
Group number:
Policy holder name
Date of birth

MonthDayYear
Date
Policy holder's social security number
Policy holder's relationship to patient
Do you have a secondary insurance?
Secondary Insurance Company Name:
Phone
Policy number
Group number
Policy holder's social security number
Policy holder name
Date of birth

MonthDayYear
Date
Policy holder's relationship to patient
Primary Care Physician
Phone

Country Code + Area CodePhone Number
Emergency Contact
Relationship
Phone

Country Code + Area CodePhone Number
Address
Do you have an Advance Directive? (living will, health care surrogate):

YesNo
I do hereby consent to any medical care which is deemed advisable or necessary by my healthcare provider and grant authority to Badia Hand to Shoulder Center,to administer and perform all examinations, treatments, diagnostic procedures and surgeries needed now or in the future. I guarantee payment for all services rendered. All medical benefits including major medical benefits, private insurance, and any other health plan, are assigned to Badia Hand to Shoulder Center. The signaturebelow confirms all of the information provided herein is true and accurate. Photocopy of this consent is to be considered as valid as the original.
Signature*

Powered by Jotform SignClear
Date

MonthDayYear
Date

BADIA HAND TO SHOULDER CENTER

Chief Complaint

History of Present illness

Prior Testing / Treatment

Review of systems

Medical Questions

Family history

Social history

Allergies

Medical History