First, how did you hear about us?

It helps us know how to keep serving Auburn well. Choose one to begin your intake. It takes about ten minutes, your answers stay in this browser tab as you go, and nothing is sent until you submit.

Prefer paper? Click here to print the form and bring it with you.

Step 1 of 10 · About You

Step 1 of 10

About You

Basic information so we can create your chart. Fill in what you have.

Legal Name
Identity
Home Address
Contact
Emergency Contact
Step 2 of 10

Guarantor

Only if the patient is a dependent or covered under someone else's account. Otherwise, continue.

Guarantor
Guarantor Address & Contact
Step 3 of 10

Insurance

Have your card handy. Co-pays and balances are due at time of service.

Assignment of benefits: I authorize payment of insurance benefits directly to East Alabama Primary Care, and I understand I am responsible for any charges my plan does not cover, including co-pays, deductibles, and non-covered services. We do not accept personal checks.

Primary Insurance
Secondary Insurance (if applicable)
Step 4 of 10

Pharmacy & Medications

Where we send prescriptions, plus your allergies and current medications.

Preferred Pharmacy
Second Pharmacy (optional)
Allergies

List any medications you are allergic to and the reaction. Write NKDA if you have no known drug allergies.

Current Medications

List each prescription or over-the-counter medication with its dosage and how often you take it.

Please note: we do not fill controlled medications, including but not limited to hydrocodone, oxycodone, Xanax, Adderall, Vyvanse, and tramadol. We will refer you to a specialist.

Step 5 of 10

Medical History

Check anything you have had. Tap again to clear.

Past Medical History
Past Surgical History

List each surgery, the performing doctor, and the date.

Step 6 of 10

Social History

A picture of your daily life helps us care for the whole you.

Tobacco & Nicotine
Alcohol & Substances
Activity & Diet
Living & Environment
Functional Status
Personal
Step 7 of 10

Health Maintenance

Recent screenings and vaccines. Approximate dates are fine.

Vaccines & Screenings
Women Only
Step 8 of 10

Family History

Check conditions that run in your family, then note which relatives below.

Conditions in the Family
Which Relatives

Note which family members (mother, father, sibling, grandparent, child) for each condition, and anything else worth knowing.

Step 9 of 10

Information Release

People our staff may speak with about your care, results, appointments, and billing.

Authorized Person #1
Authorized Person #2 (optional)
Fax / Email Authorization
I, the undersigned, allow the facsimile or email process of prescription requests, medical records, orders, and appointment listings to referred facilities to expedite my healthcare.
Step 10 of 10

Consent & Policies

Review and sign to complete your intake. Type your full name where shown.

HIPAA Patient Consent
Under HIPAA (1996) I have rights to privacy regarding my protected health information. This information can and will be used to conduct, plan, and direct my treatment; obtain payment from third-party payers; and conduct the normal business operations of this practice. I have had the opportunity to read and request a copy of the Notice of Privacy Practices. I understand I may request restrictions on how my information is used or disclosed, that the practice is not required to agree, and that I may revoke this consent in writing at any time.
Notice of Privacy Practices
Assignment of Insurance & Financial Responsibility
I authorize payment of medical benefits directly to East Alabama Primary Care. I understand I am financially responsible for all charges whether or not paid by insurance, including co-pays, deductibles, and non-covered services. We do not accept personal checks; all co-pays and balances are due at time of service.
Office & Financial Policies
A $30 deposit is required to schedule a new patient appointment and is applied to your co-pay, deductible, or procedure, held as a credit until your appointment is kept. Payment is due at time of service. We collect co-payments, deductibles, and outstanding balances at check-in. We accept debit and all major credit cards; we do not accept checks. Please give at least 24 hours notice to reschedule or cancel. Established patients are charged a $25 no-show fee, payable before the next appointment. A standard fee applies to form completion; please inquire about your specific form. A $10 non-refundable fee applies to medication prior authorization requests, and completion does not guarantee insurance approval. Patients must be seen at least every six months for medication refills; controlled substances require visits every one to three months at the provider's discretion. Please silence your phone while with your provider.
Non-Covered Services Waiver
Final Certification

I have completed this form to the best of my ability and the information is accurate. We cannot schedule you until this form is complete. Use "N/A" or "Never" where something does not apply.

✓

Thank you. Your intake is in.

Your information has been received securely. Our care team will reach out within one business day to confirm your first appointment. Questions in the meantime? Call us at 334-321-0060.

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