Patient Intake Form

First Name *

Last Name *

Date of birth *

Phone *

Email *

City *

State

Insurance Carrier ( Medicare, Aetna, BCBS, etc.) *

Member ID / Policy Number *

Primary Cardholder *

Group Number

Secondary Insurance *

Secondary Insurance Information

How long have you had this wound?

Anything else we should know?

Insurance Card — Front

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Insurance Card — Back

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Wound Photo (Optional)

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

I authorize Serenity Healthcare Associates to use the information and images submitted here for the purpose of evaluating and treating my wound care needs. I understand this information is protected under HIPAA. View our Privacy Policy.