Learn the facts about COVID-19 The health of you, your family, and your community is our top priority. Take a moment to learn how to protect yourself and prevent the spread of COVID-19.
CDC Guide to COVID-19
Phone: (956) 353-6055
Fax: (956) 353-6011
ADMINISTRATOR JOR FLORES, RN/DOPS
Cell: (956) 929-1204
j.flores@physicianpreferred-hhs.com

Intake Referral Form

    Individual Name:

    Primary Language:

    Gender:

    Marital Status:

    Phone:

    Alternate Phone:

    D.O.B.:

    Social Security:

    Medicaid:

    Medicare:

    Physical Address:

    City:

    Lives:

    Name and Relationship:

    Emergency Contact:

    Relationship:

    Address:

    Phone:

    List Tasks:

    Diagnosis:

    Assistive device?

    List:

    Hospital admissions last three months?

    Hospital Name:

    City / State:

    Reason for hospitalization

    Date of Admission:

    Date of Discharge:

    Primary Phtysician Name:

    Phone:

    Address:

    City:

    Dialysis Center? Facility:

    Days/Hrs:

    Phone

    DAHS? Facility:

    Days/Hrs:

    Phone

    Attendant of Choice:

    Phone

    Referred by whom:

    Phone

    Comments:

    Verified individual status:

    Intake#:

     

    DADS Intake Coordinator:

    Date:

        

    Signature of person completing form

    Date