WellCooRx Health Navigator Network

PLLC

New Patient Intake Packet

Patient Intake • Consents • HIPAA Authorization • Financial Policies

Section 1. Patient Information

First Name: ${entry159527532}	Middle Name: ${entry570975252}	Last Name: ${entry1897559519}
Preferred Name: ${entry1596282864}	Date of Birth: ${entry1402906056}	Sex: ${entry670601673}
Phone Number: ${entry354770509}	Email Address: ${entry460380612}
Home Address: ${entry559345308}	City/State/ZIP: ${entry496373179}
Preferred Language: ${entry72809612}	Preferred Method of Communication: ${entry1083623367}
Emergency Contact Name: ${entry2052798411}	Relationship: ${entry1793659265}	Phone Number: ${entry419982776}
Emergency Contact Name: ${entry1596616477}	Relationship: ${entry2024035405}	Phone Number: ${entry1759083556}

Section 2. Reason for Today's Visit

${LIST(entry937213053)}

Section 3. Insurance Information

Insurance Company: ${entry862745393}

Plan/Policy Type: ${entry1435571112}

Member ID: ${entry94515886}

Group Number: ${entry685045717}

Subscriber Name: ${entry1445120585}

RxBIN: ${entry751250302}

RxPCN: ${entry1057341258}

RxGroup: ${entry225424366}

${entry572893636}

${entry1726474303}

Section 4. Providers & Pharmacies

Primary Care Provider: ${entry672495896}	Clinic: ${entry510424873}	Phone: ${entry1314700275}
Next Appointment: ${entry2042230526}
Specialist #1: ${entry1877417616}	Clinic: ${entry1972483391}	Phone: ${entry906205586}
Next Appointment: ${entry2062334561}
Specialist #2: ${entry136932496}	Clinic: ${entry1675369086}	Phone: ${entry625090786}
Next Appointment: ${entry1932442803}
Specialist #3: ${entry1959189507}	Clinic: ${entry1424492849}	Phone: ${entry102032484}
Next Appointment: ${entry806875412}
Specialist #4: ${entry424562736}	Clinic: ${entry693259038}	Phone: ${entry449547059}
Next Appointment: ${entry360814032}
Specialist #5: ${entry273424284}	Clinic: ${entry156965161}	Phone: ${entry732339454}
Next Appointment: ${entry628140492}
Primary Pharmacy: ${entry1354400157}	Phone: ${entry2137438998}	Address: ${entry1643893666}
Secondary Pharmacy: ${entry903153436}	Phone: ${entry1557596797}	Address: ${entry422125932}
Additional Pharmacy: ${entry1818209376}	Phone: ${entry1546540210}	Address: ${entry1956347975}

Section 5. Medical History

${LIST(entry1249770357)}

Hospitalizations: ${entry1044681408}

Past Surgical History: ${entry298393906}

Family Medical History: ${entry1064497713}

Vaccination History: ${entry1682238305}

Social History (Smoking/Alcohol/Caffeine/Recreational Drugs/Exercise): ${entry233545473}

Section 6. Allergies

Allergy	Reaction	Severity	Current?
${entry47814881}	${entry287874213}	${entry1949407882}	${entry2064155195}

Section 7. Current Prescription Medications (Up to 10)

Medication	Strength & Form	Directions	Condition	Prescriber
${entry2086561979}	${entry2082259950}	${entry41521106}	${entry515496467}	${entry1334673571}

Section 8. Prescription Devices / OTC / Supplements

Prescription Devices: ${entry1059344252}

OTC Medications: ${entry331729448}

Vitamins: ${entry470861339}

Herbal Products/Supplements: ${entry1723172533}

Section 9. Health & Medication Concerns

Current Health Concerns: ${entry582651859}

Current Medication Issues: ${entry1860976938}

Goals for WellCooRx Services: ${entry183908548}

Additional Comments: ${entry1108995511}

Privacy Statement

WellCooRx Health Navigator Network PLLC protects your Protected Health Information (PHI) in accordance with HIPAA and applicable federal and Texas law. Your information will be used only as permitted or authorized for medication management, healthcare navigation, care coordination, billing, and healthcare operations.

Care Navigation Disclaimer

WellCooRx Health provides pharmacist-led medication management, healthcare navigation, care coordination, and patient education. We do not diagnose illnesses, prescribe medications, independently change medications, replace your physician, or provide emergency medical care. Call 911 for emergencies.

SMS Consent

${LIST(entry1811495190)}

Recurring Payment Authorization (Optional)

${LIST(entry2127924708)}

HIPAA Authorization

${LIST(entry1265245696)}

Expiration: ${LIST(entry1216135343)}

Cancellation & Refund Policy

Medication Refill Concierge Memberships may be canceled at any time by written email or text. Approved refunds are processed within three (3) business days. A $50 administrative processing fee applies to approved membership refunds. Services already rendered are non-refundable. Annual memberships are refunded on a prorated basis after deducting services already provided.

Professional Clinical Services canceled at least 24 hours in advance may be rescheduled one time without charge or refunded less a $50 administrative processing fee. Late cancellations, no-shows, or missed appointments may be charged the full service fee. Gift cards are non-refundable. Requests due to emergencies will be reviewed case-by-case.

Patient Acknowledgment

I certify that the information provided is true and complete. I have read and agree to the Privacy Statement, Care Navigation Disclaimer, HIPAA Authorization, SMS Consent, Recurring Payment Authorization (if selected), and Cancellation & Refund Policy.

Patient Name: ${entry985742380}

Legal Guardian/POA (if applicable): ${entry1001725367}

Relationship: ${entry880808312}

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