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New Patient Intake Form

East Alabama Primary Care · 1518 Professional Pkwy Ste A, Auburn, AL 36830

Phone 334-321-0060 · Please complete every section. Use N/A or Never where something does not apply.

How did you hear about us?

Google / online search
Yelp
Doctor or clinic referral
Friend or family
Word of mouth
Drove or walked by
Facebook or Instagram
Insurance directory
Saw our review sign
Returning patient
Other: ______________________

Patient Information

Last Name
First Name
Middle Initial
Date of Birth
SSN
Gender
Marital Status
Street Address
City
State
Zip
Cell Phone
Home Phone
Email
Employer / Occupation
Work Number
Contact at work? (Y / N)
Emergency Contact
Relationship
Phone
Alternate Phone

Guarantor (only if patient is a dependent)

Relation to Patient
Last Name
First Name
Date of Birth
Address
City
State
Zip
Cell Phone
Work Number
Employer
SSN

Insurance

We do not accept personal checks. All co-pays and balances are due at time of service.
Primary Plan
Policy / ID #
Group #
Effective Date
Policy Holder Name
Holder DOB
Holder SSN
Relationship
Secondary Plan
Policy / ID #
Group #
Relationship

Pharmacy, Allergies & Medications

Pharmacy Name
Phone
Address
Allergies & reactions (write NKDA if none)
Current medications, with dosage & frequency
We do not fill controlled medications (including hydrocodone, oxycodone, Xanax, Adderall, Vyvanse, tramadol). We will refer you to a specialist.

Past Medical History (check all that apply)

Acid Reflux
ADHD
Anemia
Anxiety
Asthma
Atrial Fibrillation
Bipolar Disorder
Blood Clots
Blood Transfusion
Cancer
Colon Polyps
COPD
Coronary Artery Dis.
Depression
Type 1 Diabetes
Type 2 Diabetes
Diverticulitis
Gout
Headaches
Heart Attack
Heart Failure
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
High Cholesterol
HIV/AIDS
Hyperthyroidism
Hypothyroidism
Kidney Disease
Kidney Stones
Liver Disease
Low Blood Pressure
Lupus
Osteoarthritis
Osteopenia
Osteoporosis
Rheumatoid Arthritis
Seizures
Stroke
If cancer, what type?
Other conditions
Past surgeries (surgery, doctor, date)

Social History

Tobacco/Nicotine (Current/Former/Never)
Type & how often
Duration
If quit, how long ago
Alcohol (None/Rarely/Socially/Daily)
Drinks per month
Recreational drugs
Type & how long
Family hx substance abuse
Exercise (Y/N) & type
Diet
Caffeine (Y/N), amount, type
Who do you live with?
Stress level
Pets at home? (Y/N)
Smoke/CO detectors? (Y/N)
Passive smoke? (Y/N)
Sunscreen routinely? (Y/N)
Care for yourself? (Y/N)
Difficulty seeing? (Y/N)
Difficulty hearing? (Y/N)
Difficulty concentrating? (Y/N)
Difficulty walking/stairs? (Y/N)
Difficulty dressing/bathing? (Y/N)
Difficulty errands alone? (Y/N)
Able to walk?
Sexually active? (Y/N)
# of children
Advanced directive? (Y/N)
Highest grade / level of school

Health Maintenance

Last Tetanus / TDAP
Last Flu Vaccine
Last Colonoscopy
Doctor / Clinic
Cologuard
Last Vision Exam
Last Dental Exam
Doctor / Clinic
Women: OBGYN Clinic
Last Pap Smear
Mammogram
DEXA

Family History (check all that apply)

Anemia
Anxiety
Asthma
Atrial Fibrillation
Bipolar Disorder
Blood Clots
Cancer
COPD
Coronary Artery Dis.
Depression
Diabetes
Heart Attack
Heart Failure
High Blood Pressure
High Cholesterol
HIV/AIDS
Hyperthyroidism
Hypothyroidism
Lupus
Seizures
Stroke
Sudden Cardiac Death
Which relatives for each, and any other conditions

Information Release

People our staff may speak with about your care, results, appointments, and billing.
Authorized #1: Name
Relationship
Phone
Authorized #2: Name
Relationship
Phone
I allow the facsimile or email of prescription requests, medical records, orders, and appointment listings to referred facilities to expedite my healthcare.
Signature
Date

Consent & Policies

HIPAA Consent. My protected health information may be used to conduct, plan, and direct my treatment, obtain payment from third parties, and conduct normal business operations. I may request restrictions, receive the Notice of Privacy Practices, and revoke this consent in writing.
Office & Financial Policies. A $30 deposit is required to schedule a new patient appointment, applied as a credit to your visit. Payment is due at time of service; we accept debit and major credit cards, not checks. Give 24 hours notice to reschedule. Established patients are charged a $25 no-show fee. A $10 non-refundable fee applies to medication prior authorizations. Patients must be seen every six months for refills; controlled substances every one to three months at provider discretion.
Non-Covered Services. I am responsible for co-payments, co-insurance, deductibles, and any services my insurance determines non-covered, and agree to pay upon receipt of statement.
Notice of Privacy Practices. I acknowledge I was offered the Notice of Privacy Practices upon registration as a patient of East Alabama Primary Care, LLC.
Patient Signature
Date
Print Name
If for a dependent, relationship
Please make sure you have completed this entire form before your visit. We are unable to schedule you until we have it in its entirety. Thank you, and we look forward to working with you.
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