• Patient Intake Form

    AmpleHealth medical intake form. Preserve all labels, headings, instructional/static text exactly as written. Use section breaks in the specified order and keep the Submit button as the final element.

  • Patient Info

  • Sex*
  • Date of Birth*
     - -
  • Ethnicity
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Spouse's Date of Birth
     - -

  • Emergency Contact

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance

  • MEDICAL INSURANCE: WE BILL INSURANCE COMPANIES WITH WHICH AmpleHealth IS CONTRACTED, OTHERWISE PAYMENT IS DUE AT THE TIME OF SERVICE.
  • Subscriber's DOB*
     - -
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Driver License

  • License Expiration Date*
     - -
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Signature/Authorizations

  • PATIENT OR AUTHORIZED PERSON SIGNATURE – Read and initial each statement
  • 1) I authorize all medical treatment as deemed necessary by AmpleHealth and affiliated providers.*
  • 2) I authorize release of any medical or other information necessary to process claims.*
  • 3) I authorize my insurance carrier to make payment directly to AmpleHealth for any medical services rendered.*
  • 4) I understand that I am financially responsible for all charges whether or not paid by my insurance carrier.*
  • 5) I understand I may be charged $25.00 if I do not show for an appointment or give less than a 24-hour notice to cancel or reschedule.*
  • 6) I have received and read the "Advance Directives" and "HIPAA" Notice of Privacy Practices.*
  • 7) I give permission for the staff to leave a message when calling to confirm appointments.*
  • The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
  • Date*
     - -

  • Personal Health History A

  • Date*
     - -
  • DOB*
     - -

  • Personal Health History B

  • B. History
  • Please list any family members with the conditions listed (Family members may include: mother's mother, mother's father, father's mother, father's father, father, mother, siblings, children)
  • Rows
  • Format: (000) 000-0000.

  • Personal Health History C

  • C. HOSPITALIZATIONS, SURGICAL PROCEDURES, AND INJURIES
  • Please Detail the Reason or Type (Include Psychiatric, Exclude Pregnancies). Year:

  • Personal Health History D

  • Please List All Current Medications, Including Prescriptions, Over-the-Counter Drugs, and Their Respective Dosages.

  • Personal Health History E

  • E. ALLERGIES
  • Please List All Known Allergies, Particularly to Medications, and Describe the Reaction(s).

  • Personal Health History F

  • F. MEDICAL TESTS & IMMUNIZATIONS
  • Please Provide the Year of the Most Recent Relevant Test or Immunization.

  • Personal Health History G

  • Rows
  • Smoking
  • Caffeine
  • Alcohol
  • Should be Empty: