Clone of TeleiCare Patient Intake Form

TeleiCare Patient Intake Form
Complete this form to get started. After submission, you will be directed to schedule your appointment.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you been hospitalized in the past 30 days?

YesNo
If yes, please enter facility name and discharge date
What service are you seeking?

Primary CareAcute Care (urgent issue)Weight ManagementWound CareChronic Care ManagementRemote Patient Monitoring (RPM)Transitional Care Management (TCM)Not Sure
Please briefly describe the reason for your visit
Allergies
Current Medication
Optional Take Photo of Medication List
Name of Primary Care Provider
Primary Care Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have insurance?

YesNo (Self Pay)
Insurance Provider
Member ID
Take Photo of Insurance Card (Front)
Take Photo of Insurance Card (Back)
We will verify your insurance before your appointment. You will be notified if additional information is needed.
Do you have a smartphone?

YesNo
Preferred Method of Contact

PhoneTextEmail
I consent to receive telehealth services from TeleiCare. I understand that care will be provided remotely using electronic communication and that there may be limitations compared to in-person visits. I understand that I should seek emergency care if needed.
Patient Signature*
Today's Date*

MonthDayYear
Should be Empty:

TeleiCare Patient Intake Form

We will verify your insurance before your appointment. You will be notified if additional information is needed.