Patient Experience: Complete Patient Intake Form

Date of Birth

• The patient enters their date of birth for verification and clicks Submit. The Patient Form page opens.

Welcome Page

1. The service location the patient appointment is scheduled at.
2. Navigation:
   • Patients fill out all required fields of a form to move onto the next.
   • Patients can click on the navigation to return to previous completed forms.
   • Information entered auto-saves, and patients can return to the form using the same link in the email.
   • Available forms may vary based on the selected form(s) sent by the practice.
3. The patient clicks Get Started to begin. The first form opens.

Basic Information

1. Basic Information:
   • First Name and Last Name
   • Middle Name (optional)
   • Suffix (optional)
   • Sex
   • Date of Birth
   • Primary Phone Type
   • Primary Phone Number
   • Email
   • Social Security Number (optional)
   • Address, City, State and Zip
   • Maiden Last Name (optional)
   • Martial Status (optional)
   • Driver's License photo, state and number (optional)
     • Patients can upload an image of their Driver's License/ID. If they are completing the forms with a smartphone or tablet, they can easily take and upload a photo of their ID.
2. Click Next to continue to the next page.

Note: Information entered into the forms auto-saves, with the exception of the Driver's License/ID and Insurance Card Front/Back images. If these images are uploaded and forms have not been submitted, patients will need to upload the images again.

Demographics

All fields are optional.

1. Demographics:
   • Sexual Orientation
   • Gender Identity
   • Language
   • Ethnicity
   • Hispanic or Latino
   • Race
   • Specific Races
2. Click Next to continue to the next page.
   • Click Back to go back to the previous page.

Emergency Contact

1. Emergency Contact:
   • Relationship to Contact
   • First and Last Name
   • Middle Name (optional)
   • Primary Phone Type
   • Phone Number
   • Email (optional)
   • Address, City, State, and Zip (optional)
2. Click Next to continue to the next page.
   • Click Back to go back to the previous page.

Financial Information

1. Select a Responsible Party.
   • Myself: The patient is the financially responsible for payment.
   • Same as emergency contact: The emergency contact is the financially responsible for payment.
   • Other: New contact is the financially responsible for payment. If this option is selected, the patient will be asked to enter:
     • Relationship to Responsible Party
     • First and Last Name
     • Middle Name (optional)
     • Date of birth (optional)
     • Primary Phone Number
     • Phone Number
     • Social Security Number (optional)
     • Email (optional)
     • Address, City, State, and Zip (optional)
2. Select a Method of Payment.
   • Self-Pay: The patient is financially responsible for all payments.
   • Insurance: The patient is covered by a payer. Populate the following information:
     • Upload the front and back of their insurance cards. If they are completing the forms with a smartphone or tablet, they can easily take and upload the photos of the cards.
     • Enter the primary insurance information.
       • Insurance Company
       • Policy Number
       • Insurance Plan (optional)
       • Insurance Phone Number (optional)
       • Group Number (optional)
       • Address, City, State, and Zip (optional)
     • Select the Relationship to Primary Policy Holder, if necessary.
       • If the patient is not the primary policy holder, populate the following information:
         • First and Last Name
         • Middle Name (optional)
         • Insurance ID Number (optional)
         • Social Security Number (optional)
         • Sex (optional)
         • Address, City, State, and Zip (optional)
     • Click + Add another insurance to add a additional insurances.
3. Click Next to continue to the next page.
   • Click Back to go back to the previous page.

Additional Information

1. Click Add Pharmacies to add a preferred pharmacy. The Add Pharmacies pop-up window opens.
   1. Search by Pharmacy Name or Zip code.
   2. Click Select on the desired pharmacy. More than one may be selected.
   3. Click Add Pharmacies. The Add Pharmacies pop-up window closes.
2. The patient can optionally select a referral source from the drop-down list.
3. Click Next to continue to the next page.
   • Click Back to go back to the previous page.

Medical History

1. Medical History may include the following eight sections:
   • Medication and Allergy: The patient enters current medications they are taking and any allergies including reactions.
   • Past Medical History: The patient can select applicable medical histories under Head, Ears, Nose/Sinuses, Mouth/Throat/Teeth, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Endocrine, Heme/Onc, Infections, Musculoskeletal, Skin, Neurological, and Psychiatric.
   • Family History: The patient can add family members, their known diseases, and health statuses.
   • Social History: The patient can select applicable social histories under Tobacco, Alcohol, Drug Abuse, Cardiovascular, Safety, Sexual Activity, and Birth Gender.
   • Surgical History: The patient can select applicable previous surgeries from the provided list and add comments.
   • Hospitalization/Procedure: The patient can add inpatient and outpatient procedures with applicable hospitalization dates.
   • Implantable Devices: The patient can add applicable implantable devices and unique identification numbers.
   • OB/GYN History: If applicable, the patient can add their gynecology and pregnancy history.
2. Click Next to continue to the next page.
   • Click Back to go back to the previous page.

Screening Tools

1. The patient selects the answers to the screening tool questions.
2. Click Next to continue to the next page.
   • Click Back to go back to the previous page.

Credit Card Authorization

Patients can add card(s) on file and electronically sign the authorization form. This feature is available for Tebra Payments or Patient Collect (Stripe) activated practices.

• For Patient Collect (Stripe) activated practices, review Patient Experience: Credit Card Authorization (Stripe) for more details.
• For Tebra Payments activated practices, review the following steps.
  1. The patient enters the Cardholder Name and Billing Zip Code. Then, clicks Add Card Number to enter the Card Number, Expiration Date, and CVV.
  2. Patient reviews the terms, clicks to select they agree to the terms, and electronically signs the form by typing their name in the designated field.
  3. Click Next to continue to the next page.
     • Click Back to go back to the previous page.

 

Additional Forms

Additional forms may include custom forms created by the practice, or Telehealth Consent forms.

1. The patient reviews the form(s) and answer available questions. When applicable, patient electronically signs the form by typing their name in the designated field(s).
2. Click Next to continue to the next page.
   • Click Back to go back to the previous page.

Review & Submit

1. The patient can review all of the information they  entered prior to submitting their intake forms.
   • Click Edit under any section to go back to the respective section.
   • Click Print to save a copy of the additional form(s).
2. Click Submit Form. The Confirmation page opens.
   • Click Back to go back to the previous section.

Completed Form

Once the form has been submitted, a confirmation message displays and the form is no longer accessible. If applicable, additional forms displays for patients to download.