Intake Form

KC Wellness Center Medical Intake Form

Please fill out the patient intake form below and submit it. Our team will review your information and follow up with you as needed.

Step 1 of 6

Comments

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

Instructions:

1. Please fill out the patient intake form below and submit it.
2. A representative from KC Welnness Center will follow up with you shortly.

Name(Required)

First Middle Last

DOB(Required)

Age(Required)

Social Security Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Employer(Required)

Gender(Required)

Male

Female

Marital Status(Required)

How Long?(Required)

Pharmacy(Required)

Phone(Required)

In case of Emergency who to contact:

Name(Required)

Phone(Required)

READ THOROUGHLY BEFORE SUBMITTING

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I hereby acknowledge receipt of the Notice of Privacy Practices for KC Wellness Center regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting KC Wellness Center, 1412 NW Vivion Road Kansas City, MO 64118.

CONSENT TO TREAT

I hereby authorize the Doctor’s to treat my case as they deem appropriate.

Name(Required)

First Middle Last

Date(Required)