Intake Form

By selecting the box below, I acknowledge that I understand and/or agree to the following statement:

By selecting the boxes below, I acknowledge that I understand and/or agree to the following statement(s):

By selecting the box below, I acknowledge that I understand and/or agree to the following statement:

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Have you ever had any of the following?

Please list all medical conditions, if applicable, associated with the following biological relatives:

By selecting the boxes below, I am acknowledging that I understand and/or agree to the following statements:

The Health Insurance Portability and Accountability Act (HIPAA) requires Northwest Pediatric Care to notify patients regarding how their Protected Health Information (PHI) is handled. You have the right to review the HIPAA policy and you may request a copy of the policy. Furthermore, this document will be updated annually, and you may change your permissions at any time.

With your permission we may disclose your PHI to a/or person (s) that you may identify. If an individual is not listed, we will not discuss any of your PHI with them regardless of relationship to you. Exclusions to this are entities for the purpose of payment for treatment or when legally subpoenaed.

I authorize Northwest Pediatric Care to release any personal information and/or PHI to the following permitted person(s) regarding my health care.