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NEW PATIENT INTAKE PACKET
2705 E 17th ST. Ammon, ID. 83406
Phone: 208.346.7500 / Fax: 208.346.7501
Patient Information
First Name
*
M.I.
Last Name
*
Street Address
*
Apt
City
*
State
*
Zip
*
Cell Phone
*
Email
Preferred Clinic
*
Ammon
Idaho Falls
Pocatello
Rexburg
DOB
*
+
Age
*
Gender
*
Male
Female
Gender Identity
Male
Female
Transgender
Sexual Orientation
Heterosexual
Homosexual
Bisexual
Emergency Contact Name:
*
Emergency Contact Phone:
*
Emergency Contact Relationship:
*
SS#
Primary Language
*
Do you need an interpreter?
Yes
No
Marital Status
*
Single
Married
Divorced
Separated
Partner
Widow
Other
Other
Ethnicity
*
Native American
African American
Latino
Asian
Pacific
Caucasian
Other
Other
Parent(s)/Guardian(s):
*The person completing the intake packet must be listed first*
1st Parent/Guardian Full Name:
*
🛈
DOB
+
SS#
Are you the Insured Party?
Yes
No
Relationship to Client:
Employer:
2nd Parent/Guardian Full Name:
DOB
+
SS#
Are you the Insured Party?
Yes
No
Relationship to Client:
Employer:
Is there a custody arrangement for your child?
*
Yes
No
If yes, please describe:
*
Insurance Information:
**Please note that accurate information is essential to providing timely care**
Insurance
Primary Insurance:
Secondary Insurance:
Name:
Primary Insurance:
Secondary Insurance:
Phone:
Primary Insurance:
Secondary Insurance:
Policy Holder:
Primary Insurance:
Secondary Insurance:
Relationship of Policy Holder to you:
Primary Insurance:
Secondary Insurance:
Policy Holder DOB:
Primary Insurance:
Secondary Insurance:
Policy Holder SS#
Primary Insurance:
Secondary Insurance:
Policy ID#:
Primary Insurance:
Secondary Insurance:
Group#:
Primary Insurance:
Secondary Insurance:
**Please bring insurance cards to 1st appointment**
(If you have more than two insurance carriers, please bring that information with you).