Patient Intake

Please carefully read & complete this online Patient Intake Form.

Note that submission of this form is only for patients who have already been in contact with our office staff at FOCUS. To send a general inquiry, please e-mail us at office@focusflorida.com or submit questions through our Contact Us page.

Patient Intake Form

FOCUS Patient Intake

Step 1 of 6

Patient Information
Patient Name*
Patient Nickname
Patient DOB*
Gender*
- Male
- Female

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INSURANCE INFORMATION
Primary Insurance Company*

(If none, write "none" or "self-pay.")
Policy Holder Name*
First Last
Policy Holder Relationship to Patient*
Policy Holder DOB*
Policy/Member Number*
Group Number
Emergency Contact (Someone NOT living in the household)
First Last
Emergency Contact Phone Number
Emergency Contact Relationship to the Patient
Party Responsible for Payment*
- Mother
- Father
- Other (indicate below)
If someone besides parent is responsible for payment, please indicate Name, Address and Phone Number

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MEDICATIONS
Please indicate any medications your child is taking and provide your electronic signature where prompted.
Please indicate the name of any medication(s) your child is taking, how often they take it, the reason for taking it and the start date. If your child is not taking any medication, please write, "N/A."*
If your child is taking any medications, is there anything else we should know?
Electronic Signature*
First Last
To the best of my knowledge, I have provided the latest medication information on my child. If any new medications are prescribed following the beginning of treatment at FOCUS, I will inform the therapists and office staff in order to update my child's file.

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Date This Patient Intake Form Was Completed*
Name
This field is for validation purposes and should be left unchanged.

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Patient Intake Form

Step 1 of 6

Patient Information

Parent Information

Who is authorized to pick up your child in case of emergency?

INSURANCE INFORMATION

ALLERGIES

MEDICATIONS

About

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Colonial Boulevard Location

Gulf Coast Location

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