Patient Intake Form

Welcome to Fair Health Wellness Center. To provide you with the best possible care, we ask that you complete this intake form before your first appointment.

Personal Information

Please provide the following personal information:

Full Name
Date of Birth
Address
Phone Number
Email Address
Emergency Contact Information

Medical History

Please provide information about your medical history, including:

Current medications
Allergies
Previous surgeries or hospitalizations
Chronic conditions
Family medical history

Insurance Information

Please provide your insurance information, including:

Insurance Provider
Policy Number
Group Number
Policyholder's Name (if different from patient)

Reason for Visit

Please describe the reason for your visit and any symptoms you are experiencing.

How to Submit Your Form

You can submit your completed intake form in one of the following ways:

Complete the form online through our patient portal
Print and fill out the form, then bring it to your appointment
Arrive 15 minutes early to your appointment to complete the form in our office

You can now conveniently download the form online, complete it at your own pace, and bring it with you to your appointment. This helps reduce wait times and ensures we have the most accurate information about your health history, medications, and concerns.

If you’re unable to print the form, copies will also be available at the front desk on the day of your visit.

At FHWC, we strive to make your healthcare experience as smooth and efficient as possible. Completing your intake form ahead of time is a simple way to help us provide more personalized care.

If you have any questions about the intake form or need assistance, please contact our office at +1 469-646-6200.

Click the button below to download the Patient Intake Form.

Patient Intake Form