PureHealth Outpatient Intake — Printable Forms

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Outpatient Therapy Patient Intake

Rehabilitation Services — PureHealth

Date: _______________
Site of Care: _______________

Patient Information

Last Name *

First Name *

Middle Name

Street Address *

ZIP Code *

City *

State *

Date of Birth *

Home Phone

Work Phone

SSN

Sex

M F Other

Marital Status

Race / Ethnicity

Employer

Emergency Contact

Name *

Relationship *

Home Phone *

Work Phone

Responsible Party (if different)

Name

Relationship

Home Phone

Work Phone

Primary Insurance

Insurance Company *

Group #

Co-Pay

Subscriber Name

Insurance Phone

Secondary Insurance (if applicable)

Insurance Company

Group #

Co-Pay

Medical History

Date

Referring Physician

Date of Onset / Injury / Surgery

Reason for Referral *

Check all that apply:

If yes to any above, explain and give dates:

Currently taking medications?

Yes No

If yes — medication / dosage / condition:

Consents & Agreements

Privacy Notice: PureHealth uses your health information to provide care, process payments, and operate our facility. You may request restrictions, access your records, and file complaints. A full Notice of Privacy Practices is available upon request.

I acknowledge receipt of PureHealth's Notice of Privacy Practices.

Patient Signatures

Patient / Legal Guardian Signature

Printed Name:

Date:

Responsible Party (if different)

Relationship:

Date:

Media & Privacy Consent

Date:

Staff Use Only

PureHealth Outpatient Rehabilitation Services

Staff Use Only

Patient Name

Site of Care

Date

Notation, if any, by staff:

Staff Member Signature

Printed Name:

Date

PureHealth Rehabilitation Services | Confidential Patient Record