VELORACARE CLIENT REGISTRATION FORM

Welcome to VeloraCare. This form helps us understand your health needs so we can connect you to the right medical practitioner. Please fill it out carefully. All information is confidential and used only to support your chronic or long-term care.

Patient Intake Form (#2)

Full Name

Phone no.

Patient Age

Address

City

State

Patient Gender

How Did You Hear About VeloraCare

Current Medical Condition (Hypertension, diabetes, arthritis, kidney condition, chronic pain, sickle cell, asthma, etc)

How long have you been managing this condition?

Describe your current symptoms or concerns

Has your illness been medically detected

If yes, who detected and when?

Current medications or treatment plan

Are you currently seeing a doctor?

If yes, what is the doctor’s name and specialty

Preferred type of care

Preferred time for care

What type of support do you want

What is your goal for joining VeloraCare Examples; Better management of blood pressure Daily support with medications A long-term health plan Consistent monitoring Lifestyle and nutrition guidance

Emergency contact name

Emergency contact phone number

Any allergies or important medical notes

I give VeloraCare permission to use my information to match me with the right practitioner and contact me for care support.