Patient Intake Form

Patient Information

Insurance

Primary Insurance:

Secondary Insurance:

Patient / POA Information

Are you patient? * YesNo Are you this patient’s POA? * YesNo

Wound Information

Hospital Visits

Any recent hospital visits? * YesNo

Providers

Do you have a primary care provider? * YesNo Are you currently seeing any other specialist? * YesNo Are you currently being seen by Home Health? * YesNo

Chronic Conditions

Do you have any of the following chronic conditions? * YesNo

Medications

Are you currently taking any medications? * YesNo

Pharmacy

What Pharmacy do you use? Please list name and location with phone number:

Allergies

Do you have any allergies including medications, food, latex etc? * YesNo

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Authorization

Do you give Healing Hands permission to contact any providers including pharmacies listed above to retrieve information on your behalf in order to better facilitate wound care treatment? * YesNo

Consent & Signature

By signing below, you understand that you are submitting a request for the Healing Hands Mobile Physicians group to initiate an evaluation to treat *

You are hereby giving consent to request and retrieve any medical information in order to facilitate an accurate evaluation and develop the best possible outcome for patient care including possible referral to another facility if needed.

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