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Adult Intake Form

Patient Demographics

Select One:
Marital Status

Thanks for submitting!

Would you like to receive appointment reminders?
Please select which phone number you would like to be contacted for appointment reminders:
I give permission for relevant confidential information to be left on my home answering machine and/or cell voice mail? Required
Were you referred to a specific provider at WC? Required

Medical History

Please list ALL current medications:

Emergency Contact

Responsible Party (if different from patient)

Employee Assistance Program (EAP)

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Are these visits covered by Employee Assistance Program (EAP) benefits?

If yes, please provide the following information:

Primary Insurance

Secondary Insurance

Select One:
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