Patient Intake Form — Tallahassee Neurology Associates

Personal Information

Fields marked * are required.

First Name

Last Name

Date of Birth

Sex at Birth

Last 4 Digits of SSN (optional) Used for identity verification only.

Address

Street Address

City

State

ZIP

Contact

Phone

Alternate Phone (optional)

Email Address

Preferred Contact Method

Phone Email Text

Emergency Contact

Contact Name

Relationship

Emergency Phone

Insurance Information

Please have your insurance card available. Fields marked * are required.

Primary Insurance

Insurance Name

Member ID

Group Number

Insurance Phone

Policy Holder Name (if different from patient)

Policy Holder DOB

Secondary Insurance

I have secondary insurance

Insurance Name

Member ID

Group Number

Insurance Phone

Policy Holder Name

Policy Holder DOB

Referring Provider

Tell us how you found us and about your referring or primary care doctor.

Were you referred to our practice?

Referring Doctor

Doctor Name

Practice Name

Phone

Fax

Primary Care Doctor

Doctor Name

Practice

PCP Phone

How did you hear about us?

Review & Sign

Please review your information below, read the authorization statements, and sign to submit.

Personal Information

Name

Date of Birth

Sex at Birth

Phone

Alt. Phone

Address

Contact Preference

Emergency Contact

Insurance

Primary Insurance

Member ID

Group Number

Insurance Phone

Policy Holder

Secondary Insurance

Referral & Provider

Was Referred

Referring Doctor

Primary Care Doctor

How Heard of Us

Medical History

Chief Complaint

Symptom Duration

Current Medications

Allergies

Neuro Diagnoses

Medical History

Prior Surgeries

Family History

HIPAA Privacy Notice

Your health information is protected under the Health Insurance Portability and Accountability Act (HIPAA). Tallahassee Neurology Associates will use your personal and health information only for treatment, payment, and healthcare operations. We will not disclose your information to any third party without your written authorization, except as permitted or required by law. You have the right to access your records, request amendments, and receive an accounting of disclosures. A full copy of our Notice of Privacy Practices is available at our front desk or upon request.

Medical Records Release Authorization

I authorize my prior and current healthcare providers, hospitals, and other healthcare entities to release copies of my medical records, including but not limited to diagnoses, treatment history, laboratory results, imaging studies, and consultation notes, to Tallahassee Neurology Associates for the purpose of continuity of care. This authorization is voluntary and may be revoked at any time in writing.

Authorization & Signature

By typing your name below and submitting this form, you confirm that the information provided is accurate and complete to the best of your knowledge, and that you authorize Tallahassee Neurology Associates to use this information for your medical care.

Your Full Name (Signature)

Date

I confirm that the above information is accurate and complete to the best of my knowledge, and I agree to the Records Release Authorization stated above.

Thank You — Intake Form Received

Your patient intake form has been received by Tallahassee Neurology Associates. Our team will contact you to confirm your appointment.

Please bring to your visit: a valid photo ID, your insurance card, and a list of any additional medications not listed in this form.

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