Form

Patient Intake

For first-time customers ONLY

Patient Information

First Name

Middle Name

Last Name

Birthdate

Sex

Email

Local Address

City

State

Zip

Preferred Language

Cell Phone

Home Phone

Work Phone

Referring Physician

Primary Physician

Physician's Phone

Permanent Address

Emergency Contact

Name

Relationship

Home Phone

Work Phone

Is the Patient the financially responsible party?

YesNo

If No, please complete this section

Name

Sex

Relationship

Address

City

State

Zip

Daytime Phone

Employer

Address

City

State

Zip

Is the reason for your visit the result of an accident?

YesNo

Note: Not all FMC offices accept auto or workman compensation patients.

Please check which type of accident:
Workman CompensationAutomobileOther
Date of accident

Place of accident

How did the accident happen?

Claim #

Claim Representative / Adjuster

If Workman Compensation please complete this section

Employer Name

Employer Phone

Address

City

State

Zip

Insurance Information

Insurance Company

Insured's Date of Birth

Insurance/Card Holder's Name

Relationship

ID #

Group #

Phone

Secondary Insurance Information

Insurance Company

Insured's Date of Birth

Insurance/Card Holder's Name

Relationship

ID #

Group #

Phone

HIPAA

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Lab collection services now offered, onsite and mobile!

Lab collection services now offered, onsite and mobile!

Form

Patient Intake

For first-time customers ONLY

Patient Information

Permanent Address

Emergency Contact

Is the Patient the financially responsible party?

If No, please complete this section

Is the reason for your visit the result of an accident?

Note: Not all FMC offices accept auto or workman compensation patients.

If Workman Compensation please complete this section

Insurance Information

Secondary Insurance Information

HIPAA

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