New client intake

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Company

Step one

About you

First name *

Last name *

Middle initial

Preferred name

Date of birth *

Social Security Number

Gender

Phone *

Email *

OK to text

Street address

Address line 2 (apt, unit, etc.)

City

State

Zip

Community or complex name

What brings you to Prepare to Care?

Service type

Situation is urgent

Current concerns

Additional identifying details (optional)

Height

Weight

Hair color

Eye color

Blood type

Religion

Language

Dentures

Hearing notes

Vision notes

Identifying marks

Step two

Medical history

Primary physician

Practice name

Physician phone

Pharmacy

Preferred hospital

Last hospitalized at

Last hospitalization date

Last hospitalization reason

Current medical conditions

Past medical conditions

Current medications (include dose and frequency)

Allergies

Special instructions for first responders or staff

Step three

Insurance coverage

Medicare number

Medicare start date

Primary insurance

Provider

Contact phone

Member #

Group #

Secondary insurance (optional)

Provider

Contact phone

Member #

Group #

Long-term care insurer

Step four

Contacts and directives

Emergency contacts (up to 3)

Primary

Other responsible party (e.g., adult child with power of attorney)

Name

Relationship

Phone

Statement of responsibility

Advance directives

Advance directives on file?

Designated health care agent

Living will DNR Five Wishes Surrogate named

Surrogate name

Surrogate phone

Step five

Billing preferences

Invoicing cadence

Payment method

Invoice address

Use a different billing address

Street

City

State

ZIP

Billing email

Billing contact relationship

Step six

Sign and consent

By submitting this form, you consent to Prepare to Care, Emergency Companions, LLC contacting you about advocacy services, and to automated follow-up communications (SMS, email, or voice) to the contact info you provided above. This form is encrypted in transit and in our secure vault. You may opt out of automated contact at any time.

Signer full name *

Signer email *

Signer title / relationship

I understand and consent.