NEW PATIENT INTAKE FORM Please complete the following information and fax to 850-942-2562 with appropriate records. Once received, we will call the patient with an appointment date and time. Thank you Patient Name: _____________________________________ Date of Birth: _______________________ Address: _____________________________________________________________________________ Home Phone: __________________ Work Phone: __________________ Cell: ____________________ Referring Physician: _______________________ Office Contact Person: ________________________ Office Phone: _______________________________ Office Fax: _______________________________ Insurance: _______________________________ Policy #: _______________________________ Group #: __________________ Authorization #: __________________ Expires: __________________ Reason for Referral: _______________________________________________________________ Diagnosis Code: _______________________________________________________________ Preferred Clinician in Our Office: __________________________________________________________
Records required prior to scheduling patient appointment: Most recent office visits note Problem List, Allergy List and Medication List Labs pertaining to referral Radiological Reports (CT, Ultrasound, MRI) Please contact us with any questions at 850-309-0400. Thank You!
