Get the free New Patient Intake Form - Leung Acupuncture

Date: NEW PATIENT INTAKE FORM *Please only use black or blue ink to fill out this form. Name: First Last Address: Street City State Zip Code Telephone: (Home) (Work) (Cell) Age: Height: Weight: Sex:

How to fill out new patient intake form

How to fill out a new patient intake form:

Provide personal information:

1. Full name
2. Date of birth
3. Contact information (address, phone number, email)
4. Social security number (depending on the healthcare provider's requirements)

Medical history:

1. List any past or current medical conditions
2. Include information about surgeries or hospitalizations
3. Note any allergies or adverse reactions to medications

Medications and supplements:

1. Record all prescription medications, over-the-counter drugs, and supplements you are currently taking
2. Specify the dosage and frequency

Family medical history:

1. Provide information about any hereditary medical conditions that run in your family
2. Include details about immediate family members (parents, siblings, children)

Insurance information:

1. Fill in your insurance provider's name and policy number
2. Include any additional information required by your healthcare provider for insurance billing purposes

Emergency contacts:

List at least one emergency contact person, along with their phone number and relationship to you

Signature and consent:

1. Read through the form carefully and understand the information you are providing
2. Sign and date the form to acknowledge that the information provided is accurate to the best of your knowledge
3. If applicable, provide consent to release your medical records to other healthcare providers

Who needs a new patient intake form?

1. Anyone visiting a healthcare provider for the first time usually needs to fill out a new patient intake form.
2. This form is a standard practice in the healthcare industry to gather essential information about the patient's medical history, current health status, and insurance details.
3. It helps healthcare providers understand their patients' medical needs better, optimize the treatment plan, and maintain accurate records for future reference.

For pdfFiller’s FAQs

What is new patient intake form?

The new patient intake form is a document used by healthcare providers to collect information about patients who are new to their practice.

Who is required to file new patient intake form?

New patients who are seeking medical treatment or care from a healthcare provider are required to fill out the new patient intake form.

How to fill out new patient intake form?

To fill out the new patient intake form, patients need to provide basic personal information, medical history, insurance details, and consent for treatment.

What is the purpose of new patient intake form?

The purpose of the new patient intake form is to gather important information about the patient's health history, current health status, and insurance coverage to ensure they receive proper care.

What information must be reported on new patient intake form?

Information required on the new patient intake form typically includes personal details, medical history, current medications, allergies, insurance information, emergency contacts, and consent for treatment.

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Using pdfFiller with Google Docs allows you to create, amend, and sign documents straight from your Google Drive. The add-on turns your new patient intake form into a dynamic fillable form that you can manage and eSign from anywhere.

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