Patient-Intake – Bitterroot Phlebotomy

Patient Intake Form

Bitterroot Phlebotomy

Your First Step to Convenient Healthcare

To ensure the best experience, please complete the patient intake form before your appointment. This helps me understand your needs, review your doctor’s order, and prepare for your personalized care. It’s quick, secure, and designed to make your healthcare journey smooth and stress-free. If you have questions, don’t hesitate to reach out!

Today's Date

First Name

Last Name

Street Address

2nd Address

City

State

ZIP

Date of Birth

Occupation(s)

Phone Number

Email Address

Accompanying Party or Companion

Relationship

Family Physician Name

Family Physician Location

Family Physician Phone

Insurance Carrier

Insurance Policy Number

Insurance Group Number

Do you have any sinus or allergy problems?

Yes No

Do you have any issues with venipuncture (i.e rolling/collapsed/hard to locate veins)

Yes No

Laboratory Orders/Important Documents: Please use this section to upload any files pertaining to your visit.

Your health, your home, your convenience—because every patient deserves personalized care.

Links

Contact Information

Bitterroot Phlebotomy is fully licensed and insured, ensuring professional, reliable care. I adhere to strict HIPAA guidelines to protect your privacy and confidentiality. Additionally, the business is registered with the Centers for Medicare & Medicaid Services (CMS) as a covered entity, reflecting my commitment to the highest healthcare standards.