Form — Campus Health Center New Patient Intake Form

CAMPUS HEALTH CENTER — NEW PATIENT INTAKE FORM Please complete this form before your first visit and bring it with you to your appointment. Section 1: Personal Information — full name, date of birth, student ID number, and current address. Section 2: Insurance Information — insurance provider and policy number, if applicable. Students without insurance may still be seen; please check the box marked 'no insurance' instead of leaving this section blank. Section 3: Medical History — list any current medications, known allergies, and past surgeries or hospitalizations. Incomplete forms may delay your appointment, so please answer every section as fully as possible. If you are unsure how to answer a question, leave a note in the margin and a staff member will follow up with you before your visit.