in partnership with
Etz Haim
clinic intake form
download pdf
Personal Information
Applicant First Name *
Applicant Last Name *
Gender *
Status *
Date of Birth *
Address *
City *
State *
Zip Code *
Country *
Phone Number *
Cell *
Email Address *
Patient's name (if different from applicant)
Patient's First Name
Patient's Last Name
Relationship tp applicant
Financial Information
I'm seeking a timely appointment with a specialist and will be paying cash and/or using private insurance


Monthly Income
Income from Employment (after taxes)
applicant *
$
spouse*
$
Income from Operating Business
applicant *
$
spouse*
$
Other Income
type of income
applicant *
$
spouse*
$
Interest & Dividends
applicant *
$
spouse*
$
Real Estate and Property Income
applicant *
$
spouse*
$
Social Security Benefit Income
applicant *
$
spouse*
$
Disability Income
applicant *
$
spouse*
$
Alimony, Child Support Income
applicant *
$
spouse*
$
Total Monthly Income
applicant *
$
spouse*
$
Monthly Expenses
Rent or mortgage payment *
$
Automobile payment *
$
Credit Card Payment *
$
Insurance Payment *
$
Groceries, Household Expenses, Utilities *
$
Tuition Payment *
$
Other
please specify
$
Total Monthly Expenses
$
Credit Card Debt
How many credit cards do you have with an open balance? *
Total
$
Personal Debt
How many open personal loans have you obtained from family/friends? *
Total
$
If your monthly expenses exceed your income, how do you cover the difference?
Total number of people in your household (including yourself) *
Do you own your home? *


How many vehicles do you own/finance? *
    Lease? *

Please list the make, model and year of all your vehicles*
Insurance Information
Do you have Medi-Cal? *

Do you have Medicare? *

Do you have Private Health Insurance? *

Medical Information
Are your seeking a first opinion?*

Are your seeking a second opinion?*

please briefly describe the illness, injury and/or symptoms you are seeking a consultation for*
what type of physician/specialist are you looking to meet with?*
what is your purpose/goal for this consultation?*

I understand that upon completion & submission of this form a representative of Ateres Avigail will review the information herein in order to determine whether assistance can be provided, submission of this form is not a guarantee of service. If necessary, further information may be requested. Ateres Avigail reserves the right to refuse service and/or terminate assistance at any time.

I certify that the information I have privided on this form is accurate and true. I also certify that this information may be shared with others for the purposes of rendering aid.
In partnership with