Medical Patient Client Intake — Las Vegas Healthcare Clinic

Patient Intake

Please fill out the form below for new clients and patient referrals. We need an email address for client intake. If this is a medical emergency, please call 911.

Patient Name

First Name

Last Name

Referral Name (if applicable)

Phone

(###)

###

####

Address or Pick-up Location

Medical Needs

Level of Urgency

Allergies

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

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