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New patient intake form - Integrative Urgent Care 2026

The document is a New Patient Intake Form for Integrative Urgent Care located in Glendora, CA. It collects personal information from new patients, including contact details, insurance status, and emergency contact information. The form also includes consent for medical treatment and outlines the patient's financial responsibilities regarding healthcare services. Additionally, it contains a HIPAA Information and Consent Form that explains patient privacy rights and the handling of Protected Health Information (PHI) in compliance with HIPAA regulations.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out your General Information. Enter your first name, last name, and date of birth. Ensure that your email and phone number are accurate for communication purposes.
Provide your billing address, including apartment number (if applicable), city, state, and zip code. This information is crucial for billing and insurance purposes.
In the Reason for Your Visit section, clearly describe the purpose of your appointment. This helps the healthcare team prepare for your visit.
If you have an emergency contact, fill in their name, phone number, and relationship to you. If not applicable, check the 'None' box.
Indicate how you heard about Integrative Urgent Care by checking the appropriate box.
Specify your insurance status. If insured, select your insurer from the list provided; if self-paying, indicate that option.
Review the consent statements carefully before signing at the bottom of the form. Ensure you understand what you are consenting to regarding treatment and payment responsibilities.

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2018	4.6 Satisfied (24 Votes)

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