New Patient Intake Form - Restorative Health Solutions

Personal Information

Please complete the following intake form to the best of your abilities. For non-required questions, please leave blank if you do not have the requested information or the question doesn't apply.

Name*

First Last

Age*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone*

Email*

Birth Date*

Height*

Weight*

Occupation*

Employer*

Business Phone

Spouse Name

First Last

Spouse Employer

Spouse Business Phone

Who should we contact in case of an emergency?*

Emergency Phone*

Who is your primary care physician?

Primary Care Phone

Who should we thank for referring you?

How did you hear about Restorative Health Solutions?

Website
Internet Search
Friend
Doctor
Referral
Health Lecture
Other

Step 1 of 6

Personal Information

Health Goals

Description of Issue(s)

Past Medical History

Social History

Allergies

Review of Systems

Quick Intake Instructions

SAVE AND CONTINUE

Mon.	8:00 am - 6:00 pm
Tue.	7:00 am - 1:00 pm
Wed.	7:00 am - 5:00 pm
Thu.	8:00 am - 2:00 pm
Fri.	7:00 am - 1:00 pm