Intake for First Visit » 4 My Health AZ

Intake for First Telemedicine Visit

Full Name*

Address*

Apartment #

City*

State*

Zip Code*

Home Phone

Cell Phone*

Email*

Date of Birth*

Male/Female*

Employer

Work Phone

Ext.

Marital Status*

Spouse/Partner’s Full Name

First Name

Work Phone

Cell Phone

Ext

NEAREST LIVING RELATIVE **(SOMEONE OTHER THAN YOUR SPOUSE/PARTNER)**

Name

Relationship to Patient

Home Phone

Cell Phone

Who Referred You?

Who Is Your Primary Care Physician?

Were you in an automobile accident in the last 12 months?

If so, when?

With whom may we discuss your medical information (i.e. spouse, children, friend, other relative)?

The law requires that we provide to the patient a copy of our Notice of Privacy Practices for health information. By signing below, the patient acknowledges receipt of such, or if you are the patient’s legal representative or authorized agent, you acknowledge receipt of such.

Patient Signature:*

Date*