Patient Intake and Consent Form

Please complete our online Patient Demographic Form to register yourself or your loved one for service with HomeMD Housecall Services. Once we receive your intake information along with the signed consent form, a referral specialist will contact you shortly thereafter (usually the same day) to coordinate for the first appointment with our provider staff.

Patient Name *

Patient Date Of Birth *

Home Phone

Cell Phone

Email *

Best way to contact you *

By Phone

By Email

Best time to call *

8AM - 11AM

11AM - 1PM

1PM - 3PM

3PM - 5PM

Patient's Address

Street Address

Apt. or Suite

City

State

Zip Code

Is the Patient in a Facility ? *

Yes

Primary Insurance Information :

Primary Plan Type *

Primary Member ID # *

Primary Group # *

Plan ( of Primary Insurance ) *

Secondary Insurance Information :

Secondary Plan Type

Secondary Member ID #

Secondary Group #

Plan ( of Secondary Insurance )

Emergency / Health Care Advocate

Relationship to the Patient *

Primary Care Information

( So that we can coordinate care and/or retrieve records, if we are assuming primary care )

Current or Former PCP's Name

Current or Former PCP's Phone #

Current or Former PCP's Fax #

Yes

Please have HomeMD Housecall Services assume housecall based primary care for myself or my loved one

Yes

Please have HomeMD Housecall Services provide me with information about in-home primary care

Yes

Please set me up with a connected-tablet ( NO expense to patient ) so that I can have access to telephonic visits

Yes

Please set me up with a remote monitoring service so that my vital sign readings can be reviewed in real-time by my provider

Patient History

Medical History

Surgical History

Other Pertinent Information or Notes

Ask us any questions or share details ...

Yes

I HAVE READ OR HAVE HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAVE HAD THESE QUESTIONS ADDRESSED TO MY SATISFACTION.*

Submitter's Status *

I am the Patient

I am the Health Advocate

Type in Your Name *

Date of Consent : Monday, March 1, 2021

I have read and understand the privacy policy *

Yes.

I have read the Electronic Record and Disclosure*

I have read the Electronic Record and Disclosure *

Yes.