Intake Form Medical Intake Form Fields marked with an * are required List of Medications Patient Demographics Divider Name: * Date/Time: * Gender: Male Female Address: City: State: Zip: Phone * Email * Preferred Method of Contact: Occupation: Employer: List of Medications List of Medications Divider Please list all current medications, including dosage and frequency: Emergency Contacts Emergency Contacts Divider Copy Primary Contact: Relationship: Phone Secondary Contact: Relationship: Phone Reason for Visit Reason for Visit Divider Copy Copy Services * Occupational Therapy Integrative Wellness Please describe the reason for your visit: Disclaimers and Policies Disclaimers and Policies This practice operates on a cash basis. Payment is due at the time of service. We do not bill insurance companies. A receipt will be provided for you to submit to your insurance, if applicable. Divider Copy Copy Copy Picture Release Form Picture Release Form I authorize the use of my image or likeness for the purpose of documentation, assessment, and promotional materials. I understand that my image will be used professionally and respectfully. I give my consent to use these images without compensation. Signature: Date: Divider Copy Copy Copy Copy Informed Consent Informed Consent I hereby consent to the evaluation and treatment by the occupational therapist. I understand that the practice of occupational therapy is not an exact science and I acknowledge that no guarantees have been made regarding the outcome of treatments or evaluations. Signature: * Date: * Divider Copy Copy Copy Copy Copy Additional Information Additional Information Please provide any additional information that may be relevant to your care: If you are a human seeing this field, please leave it empty.
