Patient Intake Form

Welcome to WTL Health Clinic!
To help us serve you better, please complete the intake form below. Your information will remain confidential and used only for your medical care.

Intake form

Patient Information
Social Service & Demographics
PCP & Screening
Past Medical History
HIPPA & Consent

First Name

Last Name

Date of Birth

Patient Sex

Male

Female

Decline to specify

Phone/Mobile

Address Line

City

State

Zip Code

Optional: Do you need assistance with any of the following social services? (Check all that apply)

Housing/Shelter

Food Assistance (SNAP, Food Pantries, etc.)

Health Insurance/Medicaid Enrollment

Domestic Violence Support

Legal Assistance

Clothing

What is your preferred language?

English

Espanol

Portuguese

Creole

Other

Specify language

Which of the following do you identify as? (pick all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Decline to specify

Specify

How do you identify by ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Decline to specify

Do you have a primary care provider (PCP)?

Yes

Name of the primary care provider

Contact information of the primary care provider

Have you ever had a PAP Smear?

Yes

How long ago was the PAP smear? (for example 6 months or 2 years etc.)

Have you had breast cancer screening?

Yes

How long ago breast cancer screening? (for example 6 months or 2 years etc.)

Do you have any of the following symptoms currently? (Check all that apply)

Fever

Cough

Shortness of Breath

Chest Pain

Dizziness

Pain

Nausea/Vomiting

Skin Issues

Other

Specify symptoms

Do you have any allergies?

Yes

Specify allergy

Have you ever been diagnosed with any medical conditions? (Check all that apply)

Diabetes

High Blood Pressure (Hypertension)

Heart Disease

Asthma or COPD

Kidney Disease

Liver Disease (Hepatitis, Cirrhosis)

Seizures or Neurological Disorders

Mental Health Conditions (Depression, Anxiety, etc.)

Cancer

Tuberculosis (TB)

HIV/AIDS

Other

No known medical conditions

Specify medical condition

Smoking status

Yes

How many years?

Please list any prescription medications, over the counter medications, supplements or vitamins you are taking

Please write any additional Comments/Questions/Concerns (optional)

Consent for medical information communication: Please check all that you give consent for the clinic to communicate with you.

Telephone

Mail

Fax

I have read and agree to the Terms and Conditions and Privacy Policy

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information Form and any subsequent changes if office policy. I understand that this consent shall remain in force from this time forward.

HIPAA INFORMATION and CONSENT FORM
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003.

By signing this document you are granting consent for WTL Health Clinic and all other supporting staff the authority to access any health records or medication history necessary to treat any conditions. You are consenting WTL Health Clinic to assessments and treatments necessary to treat you or clients under your guardianship. You are consenting to electronic communication (email, text, and telephone) reminders unless specified otherwise. Patient(s) understands all additional visits, additional documentation (FMLA), collaboration with other providers, or telehealth communications are a billable services. Patients are ultimately responsible for all balances.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services at www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Date of signature

Signature (Draw)

Sign Here

How it Works

Complete Form

Fill out the required information above.

Check-In at the Clinic

When you arrive, let the front desk know you've completed the form online.

See a Provider

Our medical team will review your information and assist you with your healthcare needs.

⏳ Estimated Completion Time: 3-8 mins
✅ Need Help? Call us at (401) 475-7585

Patient Intake Form

How it Works

Complete Form

Check-In at the Clinic

See a Provider

Your Health is Our Top Priority