Patient Intake Form printable pdf download

Patient Intake Form

Please present your insurance card at time of check-in.

Settlement of patient financial responsibility is expected at time of service.

TYPE OF VISIT:

Insurance (present card at check-in)

Self-pay (payment due at time of service)

On-the-job injury

Other: ___________________________________________

Patient Name:

Last:

First:

Middle:

Date of Birth:

Social Security Number:

Sex:

Spouse Name:

Marital Status:

Single

Married

Divorced

Separated

Street Address:

City, State, ZIP

Home Phone:

Preferred

Cell Phone:

Preferred

Work Phone:

Preferred

May we leave a message regarding

Employer:

Occupation:

your care (x-ray, lab results) on

your preferred phone?

Please state your reason for today’s visit:

Are you experiencing any of the following? Please stop and notify attendant immediately.

SEVERE chest pains

SEVERE shortness of breath

Uncontrolled bleeding

Allergic reaction

Any other life-threatening condition

Is this an on-the-job or other work-related injury?

If so, please complete the following:

Employer Name:

Supervisor:

Street Address:

City, State, ZIP

Description of Injury or Symptoms:

Date of Injury:

Summit Express Urgent Care 1360 Montgomery Highway Suite 114 Vestavia Hills, AL 35216 (205) 978-7550

Patient Intake Form

Related Articles

Related forms

Related Categories