Patient Intake

Patient Intake Checklist

Patient Name:

Patient DOB: //

Parent/Legal Guardian:

  1. I have received a copy of the notices listed below. My check by each notice indicates that I have received that notice and my questions have been answered.  As a patient of Shalom Health Care Center, I agree to the policies and procedures in those notices. 



          Patient Portal    If yes, email:

     2.  I understand Shalom Health Care Center utilizes the following methods to contact me regarding my care and/or leave messages regarding my care via the following method(s):  

     3.  I have completed the "Patient Registration Form" and (if applicable) "Patient Consent for Treatment of a Minor and/or Release of Information to Others" to the best of my ability and I request that information on those forms be included in my/my child's health records.

     4.  I give my consent to be examined and/or treated by Shalom Health Care Center's health care providers.  I understand and agree that any in-depth examination and/or procedure will be explained to me before I give my consent.

     5.   All documents, policies, and procedures included in the Shalom Health Care Center intake process have been explained to me, and I understand that if I have any questions, I may ask a Shalom staff member at any time.     

Leave this empty:

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Signature Certificate
Document name: Patient Intake
lock iconUnique Document ID: d46bfd358b58e8be8321adc4e48ed454d93051b5
Timestamp Audit
May 7, 2020 1:01 pm EDTPatient Intake Uploaded by Darren Huff - IP