Adult Functional Health Intake Form

NEW CLIENT FORM
Please fill in all of the information to the best of our ability.

* This information will be kept strictly confidential. Your personal information is collected for the purpose of providing health care and for administrative purposes. It will not be disclosed for other purposes without your consent other than for reasons stated in the laws.
Demographic Info
Full Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Age
Birth Date*

MonthDayYear
I identify my gender as…*

ManWoman
My preferred pronouns are:
Mobile Number

Area CodePhone Number
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
I wish to receive appointment reminders by:

EmailText MessageBoth
My cell phone carrier/provider I wish to receive reminder text messages is:
CareCard / MSP #
I have premium assistance MSP (low income, eligible for $23 towards some visits)

YesNo
Veteran K# if applicable
I have extended health coverage through:
The Plan Holder is (i.e. personal that owns this plan, either you, your spouse, mother, etc.):
My policy or member ID # is:
My plan # is:
In case of an emergency I want you to contact

First NameLast Name
Contacts Phone number

Area CodePhone Number
Relationship
Marital Status

SingleCommon-LawMarried
Spouse or Partner's Name

First NameLast Name
Number of Children
Your Occupation:
Number of hours I work per week:
I discovered Empower Health Clinic by:*

Internet Search (i.e. Google)Yelp!TwitterFacebookLinkedInSandwich Board or Walked byFlyer or BrochureMagazine or NewspaperAdvertisement or PromotionAnother BusinessFlower of Life (Selena)Other Healthcare ProviderAn existing client of Empower Health
If you found us through a google search which words did you use?
If you were referred by another healthcare provider or an existing client of Empower Health, please share their name:
Appointments & Fees
Missed Appointments

We require at least 24 hours notice during business hours and by phone if you wish to cancel or reschedule an appointment, or you will be charged the full fee of the missed appointment, and in the case of a scheduled treatment, the cost of non-reusable supplies and products prepared for you. (i.e. Monday appointments must be cancelled on the Friday before closing at 5pm.)
Should be Empty:

Demographic Info

Appointments & Fees