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17200 E. 10 Mile Rd. Suite # 260

Eastpointe MI 48021

Ph# (313) 731-2719/ Fax # (336) 654-0824

allcarehsllc@gmail.com

Primary & Wound Care

Mental Health

Weight Management

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Patient Intake Form

All patients both private pay and insured must complete the patient intake forms. We are excited to have you as our new patient. Allcare Housecalls Staffing focuses on helping our patients get on the path toward better health and weight loss by utilizing evidence-based research, medicine, and treatment.

We accept the following insurances: AETNA, UHC, BCBS, MEDICARE, PRIVATE PAY.

Medical Intake Form

Consent For Medical Treatment

Please complete the document below

First Name

Gender

Male

Female

Middle Initials:

Last Name

Date of Birth

Marital Status

Single

Married

Domestic Partner

Separated

Divorced

Widowed

Street Address

App/Unit

City

State

Postal / Zip code

Mobile Phone

Home Phone

Work Phone

Email

Preferred contact method:

Mobile

Phone

Home

Phone

Work

Phone

Email

Preferred Language:

English

Spanish

Other

Race (Please check all that apply):

White

Black

Asian

American Indian/Native Alaskan

Native Hawaiian/Pacific Islander

Other

Ethnicity:

Hispanic/Latino(a)

How did you learn about this office?

Who referred you?

Emergency Contact:

Relationship:

Address:

City, State & Zip:

Phone:

Alt. Phone:

Family Doctor:

Phone:

Other Health Provider:

Pharmacy:

Phone:

Please list individuals (and relationship) with whom you allow us to share your health information:

Name

Relationship

Thanks for submitting!

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