Dr zegarelli 2026

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4.6 out of 5

61 votes

The document is a comprehensive patient intake form for Kiest Park Medical Clinic and Smart Living Medical Center, detailing personal information, insurance details, medical history, current health issues, and financial policies. It includes sections for emergency contacts, medication lists, allergies, and consent for the release of medical records. Additionally, it outlines the clinic's no-show and cancellation policy as well as patient responsibilities regarding payment for services.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your Primary Insurance Company details, including the name, plan type, and policy number. Ensure all information is printed clearly.
Next, provide personal information such as your name, date of birth, marital status, and contact details. Be sure to circle your gender and indicate any languages spoken.
In the medical history section, check off any vaccinations you have received and list current medications. This helps ensure accurate medical care.
For current problems, list any issues you are experiencing in order of severity. Include onset dates where applicable.
Complete the emergency contact section with relevant details about who to reach in case of an emergency.
Finally, review all entries for accuracy before signing at the bottom of the form to acknowledge understanding of policies.

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2013	4.6 Satisfied (61 Votes)

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