Riverside Family Medicine Eleanor Hayes, MD · Marcus Bell, DO · Priya Nair, FNP-BC
1820 Riverside Parkway, Suite 300 · Brookfield, MA 01506 · (508) 555‑0142

NPI 1093817465
Tax ID 04‑38••••
Fax (508) 555‑0143

New Patient Intake Form

Please complete all sections before your first appointment. Print clearly in ink.

1 · Patient Demographics

Legal Name (Last, First, MI)

Date of Birth (MM/DD/YYYY)

Sex Assigned at Birth

Social Security No. (last 4)

Marital Status

Mailing Address (Street, City, State, ZIP)

Home / Mobile Phone

Email Address

Preferred Language

Race / Ethnicity (optional)

2 · Emergency Contact

Name

Relationship

Phone

3 · Primary Insurance

Insurance Carrier / Plan

Member / Subscriber ID

Group Number

Plan Type (HMO/PPO/etc.)

Subscriber Name (if not self)

Relationship to Subscriber

4 · Secondary Insurance (if any)

Carrier / Plan

Member ID

5 · Preferred Pharmacy & Referring Provider

Pharmacy Name & Location

Pharmacy Phone

Primary Care / Referring Physician

Reason for Today's Visit

6 · Current Medications

Medication	Dose	Frequency	Prescriber

7 · Allergies & Adverse Reactions

Allergen (drug, food, environmental)	Reaction

☐ Check here if no known allergies

8 · Past Medical History

HypertensionDiabetes (Type 1 / 2) High cholesterolHeart disease Asthma / COPDThyroid disorder CancerDepression / anxiety Kidney diseaseStroke / TIA Other: __________________

9 · Surgical & Family History

Past Surgeries (with year)

Family History (parents, siblings)

10 · Social History

Tobacco Use

Alcohol Use

Occupation

11 · Consent & Acknowledgement

Patient / Guardian Signature

Date

Riverside Family Medicine · Form RFM‑INT‑04 (rev. 2026) · For demonstration use — fictional practice, not a real clinic.