Patient Intake Form "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.LocationLocation 841 Central Street, Franklin, NH 03235 22 Strafford Street, Laconia, NH 03246 New Patient RegistrationName* First Last Preferred Name:*Date Of Birth* Gender at Birth:* Male Female Address* Street Address City ZIP / Postal Code Phone*Email* How would you like to receive appointment reminders?* Call Text Both Neither/Decline PersonalWe ask for the following personal information to help us provide the best possible care and resources for your health needs. Your answers are private and protected.Language:* English French Spanish Other Do you need interpreter services?* Yes No Race:* American Indian/Alaska Native Asian African American White Other Decline Ethnicity:* Hispanic/Latino Non-Hispanic/Latino Other Decline Marital Status:* Married Single Divorced Separated Widowed Partner Are you an Agricultural Worker?* Yes No Decline Household Living Arrangement* Rent Own Shelter Transitional Doubling Up Street Decline Are you a Veteran?* Yes No Decline Check off all that apply: I live alone I have a caregiver I need assistance for transfer/fall risk I have a lifeline / medic alert I have advance directives I am hearing impaired I am vision impaired Employment InformationEmployment Status: Full time Part time Unemployed Disabled Retired Employer’s Name:*Phone*Address* Street Address Occupation:*Patient Name:*Date* If the patient is a minor (under the age of 18) please complete this sectionMother’s Name:*Daytime Phone Number*Father’s Name:*Daytime Phone Number*Person responsible for the bill or Is the primary insurance holder (If different then the patient)/GuarantorParent/Guardian:*Parent Date Of Birth* Address Street Address Phone Number*Employer Name:Phone Number*Employer Address:* Street Address City State / Province / Region Insurance InformationPrimary Insurance:*ID Number:*Group Number:*Policy Holder Name:*Date of Birth:* Secondary Insurance:*ID Number:*Group Number:*Policy Holder Name:*Date of Birth:* Work Related InjuryAre you being seen for a work-related injury?* Yes No If Yes, when did the injury occur?*Employer*Contact person:*Motor Vehicle Accident InjuryAre you being seen for an injury that occurred in a Motor Vehicle Accident? Yes No Date of Accident: Payment & Financial Assistance OptionsHealthFirst is committed to providing quality health care regardless of a patient's ability to pay. Patients may qualify for discounted services through our Sliding Fee Discount Program based on household income and family size. Our staff are happy to answer questions, assist with the application process, and discuss payment options to help ensure that cost is not a barrier to receiving care.Please check all that apply: If I have a balance for services received, I understand that payment is expected at the time of service unless other arrangements have been made with HealthFirst. I understand I am responsible for payment of any applicable patient balance, including copayments, deductibles, coinsurance, or self-pay charges. I would like information about the HealthFirst Sliding Fee Discount Program to determine if I qualify for reduced-cost services. I would like to discuss a payment plan for any remaining balance after financial assistance has been considered. I decline information about financial assistance at this time. Patient Acknowledgement* I acknowledge that I have received information regarding HealthFirst's payment expectations and available financial assistance options.How did you hear about HealthFirst Family Care Center?Untitled* Friend/Family Hospital Social media (Facebook) Social Service Agency Doctor’s Office Radio Ad Website Newspaper/Billboard Ad Other: How did you hear about us?*This is to certify that the above information is true, and I hereby authorize HealthFirst Family Care Center to verify any of the information I have provided.Signature* Δ
