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Patient In-Take Form

Please take your time filling out the details so we can complete your registration. The in-take form gathers your medical history, current medications, allergies, and insurance information.

Two Ways to Complete Your In-Take

Option 1

Download & Return the PDF

Download the in-take form, fill it out at your own pace, and return it by mail, fax, email, or bring it with you to your first appointment.

Download In-Take Form (PDF)

Email: office@heelexsurprise.com
Fax: (623) 270-7442
Mail: 12329 W Bola Dr, Suite 100, Surprise, AZ 85378

Option 2

Have Us Send a Secure Link

Prefer to fill out the in-take form online? Request a secure link by text or email and we'll send one before your appointment.

Request a Secure Link

What You'll Need

Before you begin, gather the following:

  • Insurance card(s) — front and back
  • Photo ID or driver's license
  • List of current medications (name, dose, prescribing physician)
  • Past surgeries or hospitalizations and approximate dates
  • Past medical history
  • Allergy information
  • Family medical history (cardiac disease, diabetes, vascular disease)
  • Contact information for your primary care physician or referring provider, if applicable

Questions?

If you have any questions about completing the in-take form, please call our office at (623) 270-7441. We're happy to help.