Thrive Women’s Primary Care New Patient Intake and Consent

Thrive Women’s Primary Care New Patient Intake and Consent

Thrive Women’s Primary Care New Patient Intake and Consent

New patient intake and consent form based on the referenced PDF. Please answer the questions as they appear in the form; all fields are optional unless clearly marked required in the source document.
Patient Identity and Contact Information
Legal First Name
Middle Name
Legal Last Name
Preferred Name
Date of Birth

MonthDayYear
Date
Age
SSN
Driver License / State ID
State Issued
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Permission to contact - Voicemail
Permission to contact - Text
Permission to contact - Email
Emergency Contact Authorization
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Authorization Notes
Emergency Contact Authorization
Insurance Information
Insurance Status
Primary Insurance Company
Primary Insurance Plan Name
Insurance State / State Plan
Primary Insurance Member ID
Primary Insurance Group Number
Primary Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policyholder Name
Policyholder DOB

MonthDayYear
Date
Relationship to Patient (Policyholder)
Upload Insurance Card - Front

Cancelof
Upload Insurance Card - Back

Cancelof
Secondary Insurance Status
Secondary Insurance Company
Secondary Member ID
Secondary State
Secondary Group Number
Secondary Policyholder Name
Secondary Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Visit Request and Reason for Visit
Primary Care Services Requested

Other
Women's Health and GYN Services Requested

Other
Virtual and Behavioral Health Coordination Services Requested

Other Service Request
Other service request - description
Main reason for visit / symptoms / concerns
When did this issue start?
Problem Status
Already evaluated?
Prior Care and Screening History
Last time you saw a Primary Care Provider
Name of last Primary Care Provider / Clinic
Last time you saw an OB/GYN or Women's Health Provider
Name of last OB/GYN / Women's Health Clinic
Last Pap Smear Date

MonthDayYear
Date
Last Mammogram Date

MonthDayYear
Date
Last Colonoscopy Date

MonthDayYear
Date
Anthropometrics and Pharmacy
Height
Weight
Preferred Pharmacy
Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Address / Location
Pharmacy City / State
Medical History and Current Medications
Medical conditions

Other
Other medical condition details
Details for checked conditions
Medication history status
Current medications, dose, frequency, and reason
Medication categories used
Allergies and Surgical History
Allergy Status
Allergies - Details
Surgical History Status
Surgical History - Surgery / Procedure, Approximate Date, Complications
Gynecologic, Sexual, and Reproductive History
First day of last menstrual period

MonthDayYear
Date
Pregnancy / breastfeeding status
Menstrual status
Usual length of period
Flow
Painful periods?
Sexual health status
Testing requests
Current contraception method

Other
Other contraception method - specify
Number of pregnancies
Number of births
Miscarriages
Abortions
Living children
Website
Should be Empty: