Intake Form

Todays Date

Which services are you looking for?

Which services are you looking for?

Weight Management
Mental Health
Minor Skin Care Treatments
Urgent Care
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We don't have language interpretation services at our clinic. Would you need interpretation services for your appointment with provider?

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Yes
No
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Our providers can only treat Minnesota residents. Are you a Minnesota resident and currently located in the state of Minnesota?

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Yes
No
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Would you like to meet a provider in-person or through video call?

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In Person
Video Call
No Preference
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Insurance Card - Front

Insurance Card - Back

Photo ID - Front

Other - Optional

First Name

Last Name

Date of birth

Age

Mailing Address:

Address line 1

City

State

Postal Code

Phone *

Email *

Gender

Gender

Male
Female
Rather not say
Custom
Other
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Race

Race

African American
American Indian or Alaska Native
Asian
Asian Indian
White
Other
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Ethnicity

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Other
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Emergency Contacts

Full Name

Mobile Number

Patient Insurance Information:

Self Pay or Insurance?

Insurance

Self Pay

Insurance Company Name: (Primary)

ID #

Group #

Policy Holder Address Line 1

Policy Holder Address Line 2

Policy Holder Address City

Policy Holder State

Policy Holder Zip Code

Policy Holder First Name

Policy Holder Last Name

Policy Holder's Date of Birth

Do you have Secondary Insurance?

Yes
No
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Preferred Pharmacy for your Prescriptions (If applicable)

Where did you first hear about Asap Care Path?

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