New patient paperwork

Patient intake.

Complete the form below and attach clear images of your insurance card. Driver’s-license images are optional.

Before you begin

Have your insurance card ready. Each attachment must be a JPEG, PNG, WebP, or PDF no larger than 2 MB. This form is not monitored for emergencies; call 911 for urgent help.

Patient information

First name

Last name

Date of birth

Contact information

Email address

Phone number

Address

Street address

City

State

ZIP code

Emergency / secondary contact

Contact name

Relationship to patient

Email address

Phone number

Insurance

Insurance company

Member ID

Group number

Insurance card — front Required · JPEG, PNG, WebP, or PDF · maximum 2 MB

Insurance card — back Required · JPEG, PNG, WebP, or PDF · maximum 2 MB

Driver’s license Optional

Driver’s license — front Optional · JPEG, PNG, WebP, or PDF · maximum 2 MB

Driver’s license — back Optional · JPEG, PNG, WebP, or PDF · maximum 2 MB

Additional information Notes or comments

By submitting, you confirm that the information and documents belong to you or that you are authorized to provide them to Trinity Integrative Health Solutions.