Intake Form 1Patient Information2Patient Demographics3Employer4Billing5Signature Patient InformationFirst Name | Last Name* First Name Last Name Gender*Select oneMaleFemaleTransgenderDate of Birth* Cell Phone* Email Address* Appointment InformationDate of Appointment* Time of Appointment* Appointment Type*First VisitFollow Up VisitRequest A Call back*MorningAfternoonEveningPatient Home AddressStreet Address* City* State* Zip Code* Patient IdentificationDo you have a Driver's License?*Select oneNoYesMinnesota or Out-of-State Driver's License/ ID Card Number* File Upload | Minnesota or Out-of-State Driver's License or ID Card*Max. file size: 256 MB.Front ImageFile Upload | Minnesota or Out-of-State Driver's License or ID Card*Max. file size: 256 MB.Back Image Are you a student?*Select oneYesNoDo you need assistance from an Interpreter?*Select oneYesNoWhat is the patient's preferred language? Select one language*Select oneEnglishSpanishFrenchSomaliSwahiliAmharicIgboOtherAny other languages? (Please indicate below) Health Insurance InformationDo you have insurance?*Select oneYesNoFile Upload | Your Insurance Card | Front Side Image*Max. file size: 256 MB.Front ImageFile Upload | Your Insurance Card | Back Side Image*Max. file size: 256 MB.Back Image HiddenAdvance DirectivesHiddenDo you have a Living Will or Advance Directive?*Select oneYesNoMedical HistoryAny tobacco use?*Select oneYesNoHow many packs per day?*Select one12345678910Medications Please enter medications you are currently taking within the last 6 monthsMedication Name | Dose | Frequency | ReasonExample: Tylenol 325mg daily for knee pain Preferred PharmacyPreferred Pharmacy Name*In case we are to order medications today, where should we send your prescription? Pharmacy Phone #* City where Pharmacy is located* ZIP Code of the Pharmacy* Emergency Contact Who do we contact in case of an emergency?Who do we contact in case of an emergency?Parent/Guardian First Name* Parent/Guardian Last Name* Relationship to Patient* Parent/Guardian Phone Number* Responsible Party (Person responsible for paying the bill)?First Name of Responsible Party* Last Name of Responsible Party* Date of Birth* Phone Number* Insurance Company InformationFile Upload | Your Insurance CardMax. file size: 256 MB.Group Number from Card Insurance Company Name Insurance Company Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Release of Billing Information | Privacy Notice | Assignment of Benefits | Medication History AuthorityI hereby authorize treatment deemed necessary by my primary care provider at Brij Health. I authorize the release of my medical records to the medical team to which I may be referred. This authorization shall remain valid until I give written notice revoking said authorization.I hereby assign, transfer, and set over to Brij Health all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until I give written notice revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. I hereby authorize treatment deemed necessary by my primary care provider at Brij Health. I authorize the release of my medical records to physicians to which I may be referred. This authorization shall remain valid until I give written notice revoking said authorization.Signature*Please type your name here to certify that all the information on this form is true and correct.* EmailThis field is for validation purposes and should be left unchanged.