Sunshine Health Care Center
Patient Medical Intake Form
Please fill out the following form and all of its sections as completely and thoroughly as you can before your first visit.
Items with an asterisk (*) are required. Though most items are not technically required to submit this form,
it helps your doctor give you the best possible care when you complete the entire intake.
If information is missing or incorrect, your appointment could be delayed while we ask you to correct it.
Please allow at least 20 - 30 minutes to fill in this form. Currently you cannot save this information and come back to it.
Tip: If you need extra time, first write your essay answers in Notepad (or any text editor), then copy-and-paste when you are ready to submit the form.
The information provided in this form is private and confidential between you and your Doctor,
unless you submit a signed release form to give us permission to provide this information to a 3rd party. The information here is transferred across our network using SSL encryption, and is stored electronically with an extra layer of encryption to comply with HIPAA standards.
If you have a problem with this form, please contact us and let us know your specific error. You may download the pdf version below, print and fill out the form by hand.
Download printable intake form (pdf)