New Patient Intake — Specialized Clinic

Specialized Clinic · New Patient

Patient Intake &
Health History

Please complete this form as fully as possible before your appointment. Fields marked * are required. All information is confidential and protected under HIPAA.

Name & Contact

Please provide your legal name and primary contact details.

First name * Please enter your first name.

Last name * Please enter your last name.

Date of birth *MM/DD/YYYY Please enter your date of birth.

Email address *We communicate primarily via email Please enter a valid email address.

Country codee.g. +1

Mobile phone * Please enter your mobile number.

Address

Your current residential address.

Country

Address line 1 * Please enter your street address.

Address line 2Apt, suite, unit, etc.

City * Please enter your city.

State * Please enter your state.

ZIP code * Please enter your ZIP code.

Medical History

Please list all medical conditions you have been diagnosed with. If none, write "None."

Medical conditions * Please complete this field.

Surgical History

List all surgeries and procedures you have undergone. Include the procedure, approximate date, and facility. If none, write "None."

Surgeries & procedures *Procedure · Date · Facility Please complete this field.

Physician Care Team

Please tell us about other physicians you see or have seen. Include name, specialty, reason for care, and contact info. If none, write "None."

Current & past physicians *Name · Specialty · Reason · Phone / fax Please complete this field.

Allergies

List all drugs or substances you are allergic to and the type of reaction. If none, write "NKDA."

Drug / substance allergies *Substance · Reaction Please complete this field.

Medications

List all medications you are currently taking. Include name, dose, frequency, and reason. If none, write "None."

Current medications *Drug · Dose · Frequency · Reason Please complete this field.

Family History

List the medical history of your family members. Include the relative, diagnosis, and approximate age at diagnosis. If none or unknown, write "None."

Family medical history *Relative · Diagnosis · Age at diagnosis Please complete this field.

Social History

Please tell us about your lifestyle and social background.

Marital status * Please select your marital status.

Employment status * Please select your employment status.

OccupationWrite "N/A" if not applicable

Tobacco useProducts and frequency

Alcohol useFrequency and amount

Recreational drug use

Medical Insurance

If applicable. Enter "N/A" if insurance is not applicable.

Insurance provider

Primary member — full name

Covered member — full nameIf different from primary

Member ID

Group ID

Pharmacy & Imaging

Please provide your preferred pharmacy. Add an imaging preference below if you have one.

Pharmacy

Pharmacy name

Pharmacy address

Pharmacy phone

Pharmacy fax

Imaging preference (optional)

Imaging center nameWrite "N/A" if no preference

Imaging center address

Imaging phone

Imaging fax

Final Details & Consent

Almost done — just a few last things before you submit.

How did you hear about us? *

Google Instagram Facebook X / Twitter Referral — friend / family Referral — physician Other

Please select at least one option.

DetailsReferral name, physician name, etc.

Message to our teamOptional — any questions or requests

Signature — type your full legal name * Please sign by typing your full name.

Date *MM/DD/YYYY Please enter today's date.

Printed name * Please print your full name.

Relationship to patientIf signing as guardian; otherwise leave blank

✓

Thank you.

Your intake form has been received. Our team will review your information before your appointment. If you have any questions please contact us at hello@specializedphysicians.com.

New Client Form

Let’s work together.

Please fill out the info below as completely as possible and we will be in touch shortly! We can't wait to hear from you!

If something does not apply to you, please indicate that by typing ‘n/a’. Please do not leave any required fields blank.

Patient Intake &Health History