INTAKE FORM INSTRUCTIONS

1. Login to the Simplex Portal. You will receive a welcome email from Simplex Health with login details (check your SPAM or sub folders if you do not see this!). Setting up your account and completing the registration process is best completed using a laptop or desktop due to the amount of detail you need to provide. Sit, relax, & focus on your health goals!

LOGIN HERE

2. The welcome page will appear once you are logged in. Click on FILL OUT FORMS to begin filling out your intake forms.

*If you need to go back to a previous section or if you exit out of the intake paperwork: Revisit the home page, select the TOP RIGHT button and then select INTAKE FORMS. You can also click the BACK button of your browser towards the TOP LEFT/CENTER of the screen.

Basic information: You will be directed to complete some information about yourself (date of birth, address, etc). Then click NEXT at the bottom of the screen. Please note gender is listed on your insurance plan.

Health History: Please complete as much information as you can in this section. You will go through these questions with our Registered Dietitian in detail at the start of your first appointment, but the more information you provide the better! Click NEXT.

Complete the Medical Symptoms Questionnaire. Click NEXT.

Health Insurance: You will be prompted next to input your health insurance details. This information is required. Click NEXT.

Informed Consent to Services/HIPAA: Please read & review the Informed Consent forms and HIPAA forms carefully. Print copies are available at www.simplexhealth.com/forms. These forms must be signed and dated in order for your appointment to be scheduled.

By clicking “I AGREE”, you agree to the terms in the Informed Consent document and HIPAA document. Please also enter your name, e-sign both documents and insert today’s date.

Remember to e-sign your documents.

Remember to e-sign your documents. Click NEXT once you are done reviewing & completed both forms.

Release of Information: Please complete the Release of Information page. Click NEXT.

Cancellation Policy: Read and click the box to agree. Click NEXT to complete the intake process. Once you have completed the intake forms, a Simplex Health representative will reach out to confirm an appointment time!

Additional Information: Throughout your sessions, you have the ability to log food, workouts, goals, etc. that the Registered Dietitian will be able to track along with you. Please consult with your dietitian about this during the appointment as well.

INTAKE FORM INSTRUCTIONS

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