Client Intake Form "*" indicates required fields Step 1 of 7 14% CompanyThis field is for validation purposes and should be left unchanged.Today's Date * Required MM slash DD slash YYYY Enter required information below. * Required First Last Address * Required Street Address City State Zip Home Phone * RequiredAlt PhoneAlt Phone TypeWorkMobileOtherEmail * Required Date of Birth * Required MM slash DD slash YYYY Social Security Number * RequiredGender * RequiredMaleFemaleOtherRace * RequiredAfrican-AmericanAmerican IndianAsian/Pacific IslanderCaucasianHispanicMiddle EasternOtherEthnicity Marital Status * RequiredMarriedSingleDivorcedWidowedLanguage * RequiredWritten Language * RequiredNeed interpreter? * Required Yes No Employment Status * RequiredRetiredDisabledNot employedFull-timePart-timeActive Military DutySelf-employedEmployer * RequiredOccupation * RequiredSpecial Needs * Required Emergency Contact * Required First Last Emergency Contact Relationship * RequiredEmergency Contact Phone * RequiredEmergency Phone Type * RequiredHomeWorkMobile We respect the privacy of your health information. If you wish to grant permission for us to share your medical or billing information with a family member or friend involved in your care, who is not otherwise authorized by law to act on your behalf, please specify below. You are not required to grant this permission and may revoke this permission at any time by contacting the UAMS HIPAA Office at 501-603-1379.I give permission to UAMS to share health information with the following person(s): * Required No Yes Share Name #1 First Last Share #1 RelationshipSpouseChildParentOther RelativeFriendShare #1 PhoneShare Name #2 First Last Share #2 RelationshipSpouseChildParentOther RelativeFriendShare #2 PhoneShare Name #3 First Last Share #3 RelationshipSpouseChildParentOther RelativeFriendShare #3 Phone Click the following link to review or download the UAMS Notice of Privacy Practices After you click the link, close the UAMS Notice of Privacy Practices and you will return to this page to complete your intake information.Check response below * Required I acknowledge receipt of the UAMS Notice of Privacy Practices I decline to acknowledge receipt of the UAMS Notice of Privacy Practices Other Click the following link to review or download the Outpatient Services Authorization & Consent After you click the link, close the Outpatient Services Authorization & Consent and you will return to this page to complete your intake information.Check response below * Required I have read and agree to the Outpatient Services Authorization & Consent as outlined above I decline the Outpatient Services Authorization & Consent as outlined above information
