I N TA K E F O R M

Patient ______________________________________________________________________________
Address _____________________________________________________________________________
Phone _______________________________________________________________________________
Caller name _____________________________________________ Phone______________________
Emergency contact (if different) _______________________________________________________
Responsible party (bill to)_________________________________Relationship ________________
Address _____________________________________________________________________________
Phone ________________________________ Relationship to patient_________________________
Start of care date ____________________________________________________________________
Summary of services requested ________________________________________________________
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Skill level quoted (circle one): HM HHA Price quoted ____________________
LPN RN
RT LI Deposit amount quoted________________
Days and hours requested (frequency of visits) __________________________________________
Physician _______________________________ Date of birth _______________________________

Social Security # _________________________ Ht____________________Wt __________________

Primary diagnosis ____________________________________________________________________

Additional health information ________________________________________________________

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Directions to home ___________________________________________________________________
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How did you hear about us? (referral source) ___________________________________________
Person taking referral _______________________________________ Date____________________
Note: If this is an insurance referral, be sure to fill out the Insurance Verification Form (R-08)

220 S. Courtenay Parkway, Suite C, Merritt Island, FL 32952 • T: 321.459.1804 • F: 321.449.9443

HomeCompanions@health-first.org • www.Health-First.org
09-154-CHS-O110612
Copies: RN Case Mgr / Scheduling / Billing