Anchor Healthcare LLC Intake Form Adult

Anchor Healthcare LLC Intake Form

Please complete this intake form as accurately as possible. Do not use this form for emergencies. If this is a medical emergency, call 911.
Client / Patient Information
Full Legal Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Gender
Phone Number

Area CodePhone Number
Email Address
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred Contact Method
Best Time to Contact
Responsible Party / Primary Contact
Is someone completing this form on behalf of the client/patient?
Responsible Party Full Name

First NameLast Name
Relationship to Client/Patient
Responsible Party Phone Number

Area CodePhone Number
Responsible Party Email
Emergency Contact
Emergency Contact Full Name

First NameLast Name
Relationship
Emergency Contact Phone Number

Area CodePhone Number
Alternate Emergency Phone Number

Area CodePhone Number
Services Requested
What type of services are you requesting?
Please describe the reason for seeking services
Desired Start Date

MonthDayYear
Preferred Days of Service
Preferred Time(s) of Day
Requested Schedule Details
Example: Monday, Wednesday, Friday from 9 AM to 1 PM
How many hours are needed weekly?
Enter total estimated hours per week
Is the schedule flexible?
Do you prefer a male or female caregiver?
Amount you are able to pay
Example: $25 per hour, $200 per day, or monthly budget
The amount listed is per
Additional schedule or payment notes
Medical Information
Primary Care Provider Name
Primary Care Provider Phone

Area CodePhone Number
Current Diagnoses or Medical Conditions
Recent hospitalization, surgery, or major medical event?
If yes, please explain
Allergies
Current Medications
Mobility Status
Dietary Restrictions or Special Instructions
Insurance / Payment Information
Primary Insurance Provider
Member ID / Policy Number
Group Number
Policyholder Name
Preferred Payment Method
Upload Insurance Card

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Referral Information
How did you hear about Anchor Healthcare LLC?
Referring Person or Organization
Consent and Acknowledgments
Emergency Notice: This form is not monitored for emergencies. If you are experiencing a medical emergency, call 911 immediately.
Authorization to Contact
Accuracy Acknowledgment
Privacy Acknowledgment
HIPAA / Privacy Notice Acknowledgment
Signature
Should be Empty:

Anchor Healthcare LLC Intake Form

Client / Patient Information

Responsible Party / Primary Contact

Emergency Contact

Services Requested

Medical Information

Insurance / Payment Information

Referral Information

Consent and Acknowledgments