New Patient Intake Form

By signing below, I acknowledge and agree to the following:

• The information provided in this form is accurate and complete to the best of my knowledge.
• I authorize Prime Vitality Care to use this information for diagnosis and treatment purposes.
• I understand that my health information is protected under HIPAA and will be kept confidential.
• I consent to receiving communications (phone, text, email) regarding my care and appointments.
• I understand that I am financially responsible for any services not covered by insurance.
• I have reviewed the Privacy Policy and understand my rights as a patient.