Beach Primary Care - Patient Intake Form

EMERGENCY CONTACT & POWER OF ATTORNEY

Full Name:

Date of Birth:

Home Address:

City

State

ZIP Code

Place of Residence (if different from above):

Phone Number:

Email Address:

EMERGENCY CONTACT & POWER OF ATTORNEY

Emergency Contact Name:

Relationship:

Phone:

Power of Attorney (POA) Information:

POA Name (if applicable)

POA Phone

DNR (Do Not Resuscitate) Status:

Yes - DNR in place

No - Full resuscitation

INSURANCE INFORMATION

Primary Insurance:

Insurance Company:

Member ID:

Group Number:

Policy Holder Name:

Secondary Insurance (if applicable):

Insurance Company:

Member ID:

Group Number:

Policy Holder Name:

MEDICATIONS & ALLERGIES

Current Medications:

Medication Name	Dose	Frequency

Preferred Pharmacy:

Pharmacy Name and Location

Pharmacy Phone

Allergies (medication, environmental, food):

CONSENT & ACKNOWLEDGMENT

Consent for Treatment:

I consent to and authorize Beach Primary Care and Scott Heilmann, ARNP to provide medical care, treatment, and services as deemed necessary. I understand that no guarantee has been made regarding the outcome of treatment or examination.

Patient Acknowledgment:

I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that this information will be used to provide my healthcare and agree to notify Beach Primary Care of any changes to this information.

Patient Signature:

Date:

New Patient Intake Form

Consent for Treatment:

Patient Acknowledgment: