Welcome to Your Secure Patient Intake

Thank you for choosing Nexus Health Insights. This form helps us prepare for your first appointment and ensures we have the essential information to provide you with the best possible care. Please complete all required fields accurately.

Estimated time: 5-10 minutes

Your Privacy is Our Priority: All data is securely encrypted and managed in compliance with medical privacy laws including HIPAA. Your information will only be used for your healthcare and will never be shared without your explicit consent.

Patient Demographics

First Name *

Last Name *

Date of Birth *

Email Address *

Primary Phone Number *

Street Address *

City *

State/Province *

Zip/Postal Code *

Insurance Information

Primary Insurance Provider Name *

Policy/Member ID Number *

Group Number (Optional)

Medical History

I have known allergies

I am currently taking medications

Known Chronic Conditions

Diabetes

Hypertension (High Blood Pressure)

Asthma

Other Conditions

Reason for Your Visit Today (Chief Complaint) *

0/500 characters

Consent and Signature

* I have reviewed and agree to the clinic's Privacy Policy and Consent to Treatment terms. I understand that my information will be used for healthcare purposes only.

Digital Signature *

By typing your name above, you are providing a legal electronic signature that has the same legal effect as a handwritten signature.