Intake Paperwork

"*" indicates required fields

Patient Information

Name*

First Last

Email*

Phone*

Mailing Address*

Street Address City State ZIP Code

Is the patient currently making their own medical decisions?*

Yes

No

If no, is there a healthcare proxy in place? Yes or No

Yes

No

Healthcare Proxy Information (if applicable)

Name

Phone

Email

Relationship to Patient

Emergency Contact

Name*

Phone*

Email

Relationship to Patient*

Details

Where is the patient currently living?*

Street Address City State ZIP Code

Main Healthcare Provider (HCP)*

Healthcare Provider’s Contact Phone*

Healthcare Provider’s Contact Email

Please list any other involved professionals

Medical History

Terminal Illness(es)*

Date of Birth*

Age*

What is the patient’s prognosis?*

Allergies (food and/or medication)*

Other Diagnosed Health/Medical Conditions*

Current Medications*

Services

Please indicate which topics you would like to discuss.*

If Other

Email

This field is for validation purposes and should be left unchanged.

Following the free consultation, I will spend up to 2 hours with the patient/caregiver/family reviewing the services I provide specific to your unique needs.