Baig Medical Group

Patient Intake

Please complete this form before your first appointment. All information is protected under HIPAA.

Personal Information

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Gender(Required)

Email Address(Required)

Mobile Phone(Required)

Home Address(Required)

City(Required)

State(Required)

ZIP Code(Required)

Preferred Contact Method(Required)

Phone

Text

Emergency Contact

Emergency Contact Name(Required)

Relationship(Required)

Emergency Contact Phone(Required)

Insurance Information

Do you have health insurance?(Required)

Yes

Insurance Provider

Policy / Member ID

BMG membership is not insurance and does not bill insurance. Insurance information is collected for referral and coordination purposes only.

Current Health

Do you have a primary care physician before joining BMG?

Yes

Provider Name

Current Medications (include dosage if known)

Allergies (medications, environmental, food)

Chronic Conditions or Ongoing Health Concerns

Any Surgeries or Hospitalizations in the Last 5 Years?

Family Medical History (heart disease, cancer, diabetes, etc.)

Lifestyle

Smoking Status

Alcohol Use

Exercise Frequency

What do you most want to accomplish with your BMG membership?

Consent & Authorization

By submitting this form you authorize Baig Medical Group to collect and store your health information for the purposes of providing medical care. This information is protected under HIPAA and will not be shared without your consent.

Type your full name as your digital signature(Required)

Today's Date(Required)

Membership Acknowledgment(Required)

I understand that BMG membership is not insurance and does not replace emergency services.