Patient Intake Form
We will need some important documents
To expedite the process, please send this now in order to speed up the process at the medical office. For better quality, scan the following documents, otherwise, please take a picture of the following on a matte, black background with your mobile phone.
Please upload your files in the form above
Please provide the front and back of your:
1.- Identification (ID): Passport, US Driver’s License (DL), Immigration Card, State ID, any government issued ID.
2.- Insurance Card: If automobile accident, please provide your insurance company issued card.
3.- Insurance Card: Kindly also include the front and back of your private insurance company (private, Medicaid, Medicare, HMO, etc.)
4.- Police Report
5.-Accident/Incident Report
2.- Insurance Card: If automobile accident, please provide your insurance company issued card.
3.- Insurance Card: Kindly also include the front and back of your private insurance company (private, Medicaid, Medicare, HMO, etc.)
4.- Police Report
5.-Accident/Incident Report
