VERO / NEW-PATIENT FORMS / VERSION 2026-10-26
New-patient medical intake form
For an adult outpatient visit. Use your clinic's form when provided. Write unknown, not applicable, or prefer to discuss privately. Ask staff for help or another format.
Type your answers, then print or save a PDF before closing or reloading this tab. Return the copy using your clinic's chosen route. Contact the clinical team directly about concerns needing prompt attention.
1. About you Full name used for your clinic record
Date of birth (write the month in words)
Name you would like us to use; pronouns if you want to share
Who answered these questions? Who helped, if anyone?
2. How can the clinic contact you safely? These are requests for staff to confirm. Name the contact method and any limits together.
Phone number; is it shared? Best time for a call?
May we leave a voicemail? If yes, what may it say?
May we send appointment texts? Which number? Any limits?
Email or portal contact preference; any limits?
Safe mailing address, or ask staff to discuss another option
If we cannot reach you, what alternative should staff discuss?
3. Communication and access Preferred language for speaking and written information; interpreter request
What would help you use the form or attend? (For example: large print, reading help, step-free access)
4. People you want the clinic to know about An emergency contact, helper and legally authorized representative are different roles. Staff confirm the role and permitted sharing separately.
Emergency contact: name, relationship and phone; or discuss privately
Does someone help with forms or act for you? Name, role and what you want staff to clarify
5. Payment or coverage, when relevant Give coverage identifiers directly through the clinic's approved process when requested. Ask about private handling of billing communications.
Coverage or payment arrangement: plan name, self-pay, unknown, or help requested
Anything you want to discuss about billing contact or financial assistance?
6. Visit preparation and updates Main reason for the appointment, in your own words, or discuss privately
Date completed; what has changed since any earlier form?
Return through your clinic's chosen route. Keep completed copies private.