A little about you.

This goes straight to your care team and nowhere else. Takes about two minutes.

Full name

Date of birth

Phone

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Address

Step two

Who to reach.

An emergency contact, and your regular provider if you have one.

Emergency contact name

Emergency phone

Primary care provider — optional

Step three

Your health.

Your nurse practitioner reviews this before your visit. Check all that apply.

Weight (lbs)

Age

Health screening

Pregnant or breastfeeding Heart failure / fluid overload Allergy to IV fluids or needles Kidney disease or on dialysis G6PD deficiency On blood thinners (warfarin, Eliquis, etc.) None of these apply

Current medications if applicable

Medical conditions / recent surgeries if applicable

Step four

Review and consent.

One last read, then sign below.

Signature (type your full name)

Date

You're all set.

Your intake is complete and on its way to your care team. They review it before your visit, so there's nothing else you need to do. See you soon.

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