Online Temah Intake Form

Patient Information

Demographic

Chief Complians

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Is It the Same as Mailing Address? *

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Date of Birth*

Email *

Soc. Sec. *

Marital Status

Sex/Gender

State ID / Drivers License ID

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Cell Phone *

Home Phone *

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Race

Hispanic or Latino Descent *

Power of Attorney & Emergency Contact

Power of Attorney / Guardian

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P.O.A Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Fax #

Relationship to Patient

Emergency Contact

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Relationship to Patient

Primary Insurance

Name *

First

Last

Claim Address

Address Line 1

Address Line 2

City

State

Zip Code

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Policy/ID Number

Group Number

Soc. Sec. Number *

Secondary Insurance

Name (copy) *

First

Last

Claim Address

Address Line 1

Address Line 2

City

State

Zip Code

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Policy/ID Number

Group Number

Primary Physician

Name *

First

Last

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Phone *

Fax

Pharmacy

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Name *

Phone *

Zip Code

Fax

Therapist

Name *

First

Last

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Phone *

Fax

Other Provider

Name *

First

Last

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Phone *

Fax

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Insurance ID

Click or drag a file to this area to upload.

State/Driver's ID

Click or drag a file to this area to upload.

Please provide a photocopy of each side of your insurance card(s) – front and back and a photo identification card.

Online Temah Intake Form

Demographic

Power of Attorney & Emergency Contact

Power of Attorney / Guardian

Emergency Contact

Primary Insurance

Secondary Insurance

Primary Physician

Pharmacy

Therapist

Other Provider

Keep in Touch with Us

Our Contact Details

410-521-8000 /
443-272-2572

Office:

Quick Links

Business Hours

Online Temah Intake Form

Demographic

Power of Attorney & Emergency Contact

Power of Attorney / Guardian

Emergency Contact

Primary Insurance

Secondary Insurance

Primary Physician

Pharmacy

Therapist

Other Provider

Keep in Touch with Us

Our Contact Details

410-521-8000 / 443-272-2572

Office:

Quick Links

Business Hours

410-521-8000 /
443-272-2572