Initial Intake form

Initial Intake

Welcome to the healthcare management goup inc.! In order to serve ypu better, please take a moment to complete this form, if you require assistance, please call or email the office.

Patient Information

Case Information

Do have a legal representative? ( if yes please provide the name )
Do you have extended health care benefits coverage? ( if yes please provide name of insurer )

Patient Signature

To the best of my knowledge, I certify that the information provided above is true and correct.

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