Telehealth Patient Intake Form

Personal Information

First Name

Last Name

Date of Birth

Phone Number

Email

Address

City

State

Zip Code

Emergency Contact

Name

Relationship

Phone Number

Insurance Information

Insurance Provider

Policy Number

Group Number

Reason for Visit

Please describe the reason for your telehealth visit

Medical History

List any past or current medical conditions

Current Medications

Allergies

Consent

I consent to telehealth services.