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PATIENT INTAKE FORM

Westside Medical Center | Form MR-2025-INT

Patient Information

Name:Sarah Johnson

Date of Birth:03/15/1985

SSN:482-55-7891

Phone:(555) 867-5309

Email:[email protected]

Address:1847 Oak Avenue, Portland, OR 97201

Emergency Contact

Name:Michael Johnson

Relationship:Spouse

Phone:(555) 234-5678

Medical Information

Primary Diagnosis:Type 2 Diabetes

Medications:Metformin 500mg (twice daily)

Allergies:Penicillin, Sulfa drugs

Blood Type:O+

Insurance Information

Provider:BlueCross BlueShield

Policy Number:BC-449281-PPO

Group Number:GRP-78452

Consent: I authorize Westside Medical Center to use and disclose my health information for treatment, payment, and healthcare operations. I understand that I may revoke this authorization at any time by submitting a written request.

Sarah Johnson

Patient Signature

01/15/2025

Date

CONFIDENTIAL - Protected Health Information (PHI) under HIPAA

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