Patient Intake

Intake Form

Patient Information
Last name*
First Name*
MI
Address*
Address Address 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Patient Employer
Work Phone
Birth Date*
SS#*
Gender*
Cell Phone
Pharmacy Phone
Responsible Party Information
Last Name
First Name
MI
Address
Street City State / Province / Region ZIP / Postal Code
Birth Date
SS#
Employer
Employer Address
City
State
Work Phone
Relationship To Patient
Insurance Company Information
Primary
Insured's Name
Ins Company
SS#
Birth Date
Employer
Phone
ID number
Group
Secondary
Insured's Name
Ins Company
SS#
Birth Date
Employer
Phone
ID number
Group
I have completed this form accurately and completely. I certify that I am the patient or the legal representative of the patient. I understand that full payment is due at the time of treatment, unless arrangements are made otherwise. I agree to pay any amount not covered by insurance. I authorize the release of any information necessary to process insurance claims.

Medicare Only: My signature requests that payment be made to physician. I am responsible for deductible, coinsurance and non-covered services only.
Date

Location
Winchester Medical & Health Center
28 East Waterloo Street
Canal Winchester, Ohio 43110
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