Intake Form
Patient Information
Patient Name
*
First Name
Last Name
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Email
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Gender
*
Please Select
Male
Female
Prefer not sat
How did you hear about Fusco Care / who referred you?
Which service(s) are you interested in?
Massage Therapy Referral
Labwork (Quest or Labcorp)
Physical Examination
IV Drip Therapy
Trigger Point Injections
Establishing Care
Medication Refill / Managment
Other
Are you interested in Telemedicine or In-Person Appointments?
Telemedicine
In-Person
Not sure
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relation To The Patient
Insurance Information
If you have your insurance card accessible, please upload a picture of the front.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Insurance
Insurance Company
*
Member ID
*
Group Number
*
Insurance Phone Number
Insurance Company Address
Person Responsible for the account
*
First Name
Last Name
Relationship to account holder (if yourself, write "self")
*
Date of Birth of the account holder
*
-
Month
-
Day
Year
Date
Gender of account holder
*
Please Select
Male
Female
Prefer not say
If you have your insurance card accessible, please upload a picture of the front.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have secondary insurance?
*
Yes
No
Secondary Insurance
Secondary Insurance Company
Member ID
Group Number
Insurance Company Address
Insurance Phone Number
Person responsible for the account
First Name
Last Name
Relationship to account holder (If it is yourself, write "N/A")
DOB of the account holder
-
Month
-
Day
Year
Date
Gender of the account holder
Please Select
Male
Female
Prefer not say
Medical Information
Are you taking any medications currently?
*
Yes
No
If yes, please list them and the dosage.
Have you ever, or do you currently smoke or use Tobacco products?
*
Yes
Not currently, but have in past
No, never
What is the primary reason for your appointment?
*
Do you have a medical history of any of the following?
*
Anemia
Headaches/Migraines
Cancer
Arthritis
Diabetes
Joint replacement
Heart disease
High blood pressure
Heart Attack
Thyroid disorders
Stroke
Fibromyalgia
Kidney dysfunction
Blood clots
High cholesterol
None of the above
Depression
Anxiety
Neuropathy
Other
If other, please list here
Do you have any allergies? If yes, list them here
*
If you are looking to do labwork, do you have a lab preference?
Quest Lab
Labcorp
Unspecified / Other
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