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Patient Intake Form
Step
1
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5
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Patient & Contacts
Name
(Required)
First
Middle
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Sex at Birth
(Required)
Male
Female
Phone
(Required)
Email
(Required)
Marital Status
Single
Married
Divorced
Widowed
Other
Address
(Required)
Street Address
Address Line 2
City
State
ZIP / Postal Code
Emergency Contact
Name
First
Last
Phone
Email
Consent to release medical information
(Required)
Yes
No
No Emergency Contact
Signature
(Required)
Date Signed
(Required)
MM slash DD slash YYYY
Insurance
Do you currently have health insurance?
(Required)
Yes – I have active health insurance
No – I am uninsured / self-pay
Insurance Company
(Required)
Insurance Member ID
(Required)
Upload Insurance Card (Front and Back)
(Required)
Drop files here or
Select files
Max. file size: 50 MB, Max. files: 2.
Clinical
Main reason for your visit
(Required)
List of Medications
(Required)
Please list all medications and dosage you are currently on. If none, please mark N/A
Do you have any medication allergies?
(Required)
Yes
No
If yes, please list medication allergies and reaction
(Required)
Consents
Communication Preferences
(Required)
I consent to receive voicemail messages about my care and appointments.
I consent to receive text messages for reminders, scheduling, and brief follow-up communication.
I consent to receive emails with secure forms, visit information, and practice updates from Synergy Medical Group.
Please let us know how we may contact you regarding your care, reminders, and practice updates.
Consent
(Required)
I agree to the general consent to be treated
I consent to receive medical evaluation and treatment from Synergy Medical Group and its healthcare providers. This includes examinations, diagnostic testing, preventive care, chronic disease management, medication management, referrals, and telehealth services when appropriate.
I understand that no guarantees can be made regarding the outcome of any treatment. I may ask questions or decline treatment at any time.
Consent
(Required)
I agree to the Financial Responsibility & Insurance Billing Consent
I understand and agree that:
Synergy Medical Group may bill my insurance for covered services.
I authorize the release of information necessary to process claims and authorize payment of benefits directly to the practice.
I am financially responsible for all charges not covered by my insurance plan, including copayments, deductibles, coinsurance, non-covered services, and services denied by insurance.
Insurance verification or authorization does not guarantee payment.
I am responsible for providing accurate and up-to-date insurance information.
I agree to pay any outstanding balances in a timely manner.
Unpaid balances may result in late fees, collection efforts, or restrictions on scheduling future appointments.
I understand that Synergy Medical Group charges a $50 fee for any appointment that is not canceled at least 24 hours in advance, and I agree to be responsible for this fee.
Consent
(Required)
I agree to the Labs & Third Party Services Financial Responsibility
I understand that laboratory testing, imaging studies, pathology services, durable medical equipment, prescriptions, and other services performed by third-party facilities are billed independently from Synergy Medical Group.
I am responsible for all charges from outside providers, even if the services were ordered by my Synergy Medical Group provider.
I understand that:
Third-party vendors set their own pricing.
These charges may apply toward my deductible or coinsurance.
Questions regarding these charges must be directed to the vendor or insurance carrier.
I agree to ask Synergy Medical Group if I have concerns about cost or alternative options.
Consent
(Required)
I agree to the Office Policies Consent
I acknowledge that Synergy Medical Group maintains policies regarding scheduling, cancellations, no-show appointments, and late arrivals. I agree to follow these policies and understand that failure to comply may result in fees or limitations on scheduling future appointments.
I understand that Synergy Medical Group is not an emergency medical service. If I experience a medical emergency, I must call 911 or go to the nearest emergency facility.
I agree to respect the practice’s guidelines for professional behavior, appointment preparation, and timely communication related to my care.
Consent
(Required)
HIPPA Acknowledgement
Synergy Medical Group is committed to protecting your personal health information. This message serves as your Notice of Privacy Practices acknowledgment.
By receiving care from Synergy Medical Group, you acknowledge that:
You have been provided access to Synergy Medical Group’s Notice of Privacy Practices, which explains how your health information may be used or disclosed as permitted by law.
You understand that you may request a printed or electronic copy of the full Notice at any time.
You understand your HIPAA rights, including the right to access your records, request corrections, request restrictions, request confidential communication, and receive an accounting of disclosures.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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