New Patient Intake Form - Patient Medical History - HIPAA Compliance Patient Consent Form

Sep 19, 2026

Upload by Xiajie

New Patient Intake Form for collecting personal details, contact information, emergency contacts, and insurance data (primary and secondary coverage). Includes payment policies covering copays, deductible/co-insurance/co-pay responsibility, copay/no-show/NSF fees, and prescription refill and denial rules. Adds sections for patient medical history covering allergies, family history, social habits, surgical and medical histories, and current medications. Concludes with HIPAA Compliance Patient Consent Form language covering privacy practices, patient rights, and consent/updates.

LanguageEnglish

CategoryForms

FormatPDF

Pages5

Reading Time2 min

AccessFree to download

New Patient Intake Form

Patient Medical History

HIPAA Compliance Patient Consent Form

NEW PATIENT INTAKE FORM | PLEASE PRINT AND COMPLETE ALL ENTRIES | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | FIRST NAME | | | LAST NAME | | | | | | DATE OF BIRTH
/ / | | | SEX
❑ Male ❑ Female | SOCIAL SECURITY | | | PHONE NUMBER | | | EMAIL ADDRESS | | | | | ADDRESS | | | | | | | | | | | | CITY | | | | | | | | STATE | | ZIP CODE | | MARITAL STATUS
❑SINGLE ❑MARRIED | | SPOUSES NAME | | | SPOUSE PHONE NUMBER | | | | | | | EMERGENCY CONTACT | | RELATIONSHIP | | | PHONE NUMBER | | | | | | | INSURANCE INFORMATION | | | | | | | | | | | | DO YOU HAVE INSURANCE?
❑YES ❑NO | | | PRIMARY CARD HOLDER
❑SELF ❑SPOUSE. ❑PARENT. ❑OTHER | | | PRIMARY POLICY HOLDER NAME | | | | | | PRIMARY INSURANCE COMPANY | | | PRIMARY ID NUMBER | | | PRIMARY GROUP NUMBER | | | | | | DO YOU HAVE SECONDARY INSURANCE?
❑YES ❑NO | | | SECONDARY CARD HOLDER
❑SELF ❑SPOUSE. ❑PARENT. ❑OTHER | | | SECONDARY POLICY HOLDER NAME | | | | | | SECONDARY INSURANCE COMPANY | | | SECONDARY ID NUMBER | | | SECONDARY GROUP NUMBER | | | | | | PAYMENT POLICIES | | | | | | | | | | | | ● You are financially responsible for anything insurance does not cover. All copays are due and payable at each visit. The amount your insurance will allow and pay for and your financial responsibility is determined by your insurance company and the policy you have chosen. Your claim will be processed according to the benefits of your insurance plan. The deductible, co-insurance and co-pay are your financial responsibility. It is your
responsibility to understand your insurance plan.
● $5 Fee for Co-pays not paid at the time of service.
● $50 No Show Fee for any Missed Appointment that was not cancelled or rescheduled 24 hours prior to the appointment. Please be considerate and call at least 24 hours before your appointment if you cannot come in.
● $35 NSF charge for any returned check from the bank.
● If you are a private patient without insurance, all charges are due at the time of the visit. We do not send a statement to private pay patients. | | | | | | | | | | | | PRESCRIPTION POLICY | | | | | | | | | | | | PHARMACY NAME PHARMACY PHONE NUMBER | | | | | | | | | | | | ● Please do not wait until your last pill to call for a refill. There is a 72 hour turn around for prescription refills. If you have not seen the Physician in six months, the prescription will be Denied. | | | | | | | | | | | | PATIENT SIGNATURE | | | | | | | | DATE | | | PATIENT MEDICAL HISTORY | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | | Allergies
NONE/Known Allergies Adhesive Tape Anesthesia Aspirin Codeine
Dairy Products Iodine/Shellfish/Contrast Latex Morphine Penicillin
OTHER: | | | | | | | | FAMILY HISTORY – Please indicate if any of your immediate relatives have had any of the following by placing an X in the appropriate box.
MOTHER FATHER | | | | | | | | Anesthesia Problems | | | | | | | | Arthritis | | | | | | | | Cancer | | | | | | | | Diabetes | | | | | | | | Heart Problems | | | | | | | | Hypertension | | | | | | | | Stroke | | | | | | | | Thyroid Disorder | | | | | | | | SOCIAL HISTORY
◻Yes ◻No-Do you drink alcohol? ◻ Daily ◻Weekly ◻Infrequently ◻ Recovering Alcoholic
◻Yes ◻No-Do you smoke? ◻ Smoke ( packs per day) ◻ Chew
◻Yes ◻No-Do you drink caffeine? ◻ Daily ◻Weekly ◻Infrequently
◻Yes ◻No – Are you sexually active?
◻Yes ◻No – Do you wish to be checked for STDs? | | | | | | | | Surgical History: Please list any hospitalizations, surgeries, fractures or major illnesses you have had.
TYPE OF SURGERY YEAR or DATE DOCTOR | | | | | | LOCATION | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

FAQs

What information does the New Patient Intake Form collect?

It collects personal identifiers (name, DOB, sex), social security number, phone and email, address details, marital status and spouse information, emergency contact information, and primary/secondary insurance details.

What are the payment policy rules included in the form?

The form states responsibility for charges not covered by insurance, payment of copays at each visit, and outlines fees for unpaid copays, missed appointments not cancelled/rescheduled 24 hours ahead, and returned checks (NSF).

What does the HIPAA Compliance Patient Consent Form cover?

It references the Notice of Privacy Practices, describes patient rights under the law, explains that patients review the notice before signing consent, and covers restrictions on how protected health information is used or disclosed.

Sep 19, 2026

Upload by Xiajie