Telehealth Appointment Check-in Form
Name of Patient
*
Name of Guardian (if patient is under 18)
Patient's Date of Birth
*
Patient's Address
*
Patient's Social Security Number
*
Patient's Marital Status
*
Patient's Cell Phone
*
Do you give consent to receive text messages from Your Provider? (Your Provider is not responsible for carrier charges for text messages).
*
Yes
No
Race
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Declined to Specify
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Declined to Specify
Preferred Language
*
English
Spanish
Burmese
Shahili
Kinyarwanda
Nepali
Karen
Somali
Other
Housing Status
*
Not Homeless
Shelter
Street
Doubling Up
Transitional
Other
Gender Identity
*
Male
Female
Female to Male/Trans Man
Male to Female/Trans Women
Genderqueer
Choose not to disclose
Sex at Birth
*
Male
Female
Are you a Veteran?
*
Yes
No
I authorize Your Provider to download my prescription history for the purpose of complete/continued treatment. I have reviewed this consent form and give my permission to Your Provider to use and disclose health information in accordance with it.
Signature
*
Submit
Should be Empty: