Patient Intake Form | Hampton Homecare

Contact

Appointment Request Form

Please complete all required fields so we can schedule your appointment.

After you submit, a confirmation message will appear. You can call us if you need help.

Consent

You are receiving this communication because your doctor prescribed sleep equipment and supplies for you. Please complete the requested information and select a preferred and alternate appointment date and time slot. We will make every effort to accommodate your primary selection. An appointment notification will be sent; in the event you need to cancel or change your appointment please contact us at [email protected] or use live chat on our website at https://hamptonhomecare.com/contact-us.

I consent to communicate by phone, video, and electronic methods. Carrier rates may apply.

Yes, I consent

Personal Information

First name

Last name

Phone number

Date of birth

Gender

Address

Street address line 1

Street address line 2

City

State

ZIP code

Emergency Contact

Full name

Relationship

Phone number

Insurance / Financial Responsibility

Responsible party

Patient Guardian

Insurance exists

Yes No

Insurance provider name

Insurance member name

Insurance member ID number

Insurance claims address

Insurance provider phone number

Insurance Card Uploads

For this first phase, the image is converted to base64 before submitting.

Front of insurance card

Back of insurance card

Preferred Appointment Dates

Preferred date option 1

AM PM

Preferred date option 2

AM PM

Agreement

View policies

Patient 13 or older (For minors this consent only applies to reproductive and substance abuse services. Minor patients will be counseled about the importance of discussing health care concerns with a parent or other trusted adult.)

I agree to the policies

Type your full name to sign

Security Check

Please complete the security check before submitting.

Need help? Call us and we can submit this with you.