Intake Form

Basic details about your child and how to reach you. This first page covers the contact, doctor and insurance questions - later pages won't ask for these again.

Before you start

This packet has 9 short pages plus a final review, and takes about 10-15 minutes.
Questions marked * are required. Everything else is optional - but please fill in as much as you can, so our team has what they need before your visit.
Some pages touch on similar topics - each page covers a different area, so a little overlap is normal.
Your answers save on this device as you go, and you'll sign with your finger or mouse on a few pages.

Questions marked * are required - please answer the rest as best you can.

Date *

Time *

Patient name *

Parent / guardian name *

Date of birth *

Age (calculated from date of birth)

Address *

City *

State *

Zip code *

Contact information

Home phone

Cell phone *

Email *

Would you like to receive text reminders?

Physician name

Physician phone

Fax

Insurance

Insurance name (primary)

Insurance number (primary)

Insurance name (secondary)

Insurance number (secondary)

Group #

ID #

Medical history

Medications (write "None" if none)

Allergies (write "None" if none) *

Referred by