2705 E 17TH ST • Ammon, ID 83406 • 208.346.7500 • fax 208.346.7501
NEW PATIENT INTAKE PACKET
Patients Information: Today’s Date: _____________
First Name: ______________________ Middle Name: ______________________ Last Name: _____________________
Note: Please spell name exactly as spelled on your insurance card.
Street Address: ______________________________ City: ____________________ State: __________ Zip: __________
Home Phone: __________________ Cell Phone: __________________ Email: __________________________________
DOB: _____________Age: ____ Gender: ___________ Gender Identity: ___________ Sexual Orientation: ___________
SS#: _________________Primary Language: _________________________ Do you need an interpreter? Y ____ N ____
Marital Status - Single: ____ Married: ____ Divorced: ____ Separated: ____ Partner: ____ Widow: ____ Other: ______
Note: If divorced, please supply Pearl Health Clinic with legal documentation of custody to ensure that privacy rights can be enforced.
Ethnicity: Native American ____ African American ____ Latino ____ Asian ____ Pacific ____ Caucasian ____ Other ___________.
Parent(s)/Guardian(s): **The person completing the intake packet must be listed first**
1st Parent/Guardian Full Name: _______________________________ DOB: ______________ SS#: _________________
Are you the Insured Party? Y ____ N ____ Relationship to Client: __________Employer: _________________________
2nd Parent/Guardian Full Name: ______________________________ DOB: ______________ SS#: _________________
Are you the Insured Party? Y ____ N ____ Relationship to Client: __________Employer: _________________________
Emergency Contact: ___________________________ Home Phone: _______________ Cell Phone: ________________
Insurance Information: **Accurate information is essential to providing timely care**
**Please bring insurance cards to 1st appointment**
If you have more than two insurance carriers, please bring that information with to your 1st appointment.
Primary Insurance Carrier:
Name: ______________________________________
Phone: _____________________________________
Policy Holder (PH): ___________________________
Relationship of PH to you: _____________________
PH DOB: ____________ PH SS#__________________
Policy ID#: __________________________________
Group#: ____________________________________
Secondary Insurance Carrier:
Name: ______________________________________
Phone: _____________________________________
Policy Holder (PH): ___________________________
Relationship of PH to you: _____________________
PH DOB: ____________ PH SS#__________________
Policy ID#: __________________________________
Group#: ____________________________________
2705 E 17TH ST • Ammon, ID 83406 • 208.346.7500 • fax 208.346.7501
Sliding Scale Plan: Page 2
*If you are without insurance, you may opt to see an Intern (based on availability) or apply for our sliding scale program. To apply for the Sliding
Scale Plan please complete the Sliding Sc...
