Online Intake Form – Slim Lyfe

Step 1 of 8 - About you

1. About you

1.1) Name*

First Last

1.2) Address*

1.3) Phone number*

1.4) Email Address*

2. Employment Information

Employer:

Occupation:

Employer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone:

3. Emergency Contact

Name

First Last

Relationship:

Phone

Primary Care Provider:

4. Pharmacy and Labs

Preferred Pharmacy:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Preferred Lab:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

5. Insurance

Primary Insurance:

Secondary Insurance:

Please present your insurance card to staff at the front desk.

6. Financial Policy

Thank you for selecting [YOUR CLINIC NAME] for your healthcare needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. [FOR CASH-ONLY PRACTICES] Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. For your conven-ience, we accept [PAYMENTS YOU ACCEPT (E.G., VISA, MASTERCARD, CHECKS, ETC.)]. [FOR PRACTICES ACCEPTING INSURANCE] Please be advised that payment for all services will be due at the time of services rendered, unless prior arrangements have been made. We accept some forms of insurance. Please discuss your insurance coverage with a staff member. I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees, and court costs. I have read and understand all of the above and have agreed to these statements.

7. Consent

Name*

Signature*

Date*

Untitled

First Choice

Second Choice

Third Choice

Name

This field is for validation purposes and should be left unchanged.