CAREPATH

Patient Intake Profile

Complete your patient intake so CarePath can coordinate safe, reliable transportation tailored to your needs.

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Personal Information

Enter your information.

First NameLast NameStreet AddressZIP CodeCityCountyStateDate of Birth

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Contact and Communication

Choose how CarePath should contact you and send ride updates.

Phone NumberEmail AddressPrimary LanguagePreferred Method of ContactThe patient has access to a smartphone.Send appointment and transportation reminders.

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Coverage and Ride Planning

Provide insurance, funding, and scheduling information used to coordinate transportation.

Transportation Funding SourcePrimary Insurance ProviderMember or Policy IDRide Scheduling RequirementOther Coverage or Scheduling Information

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Doctors and Medical Offices

Add each doctor, clinic, hospital, pharmacy, or treatment center you regularly visit.

Medical Provider #1

Doctor or Provider NameOffice or Facility NameSpecialty or Type of CareOffice Phone NumberOffice AddressTransportation or Appointment Notes

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Accessibility and Transportation Needs

Select anything that may affect the vehicle, pickup, drop-off, or assistance required.

Wheelchair-accessible vehicleNon-transferable wheelchairStretcher transportationUses a walkerUses a caneTravels with oxygenTravels with a service animalCaregiver or companion rides alongNeeds door-to-door assistanceVision-related assistanceHearing-related assistance

Other Accessibility or Transportation Needs

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Transportation Barriers

Explain circumstances that make it difficult for you to reach medical care.

No personal vehicleNo backup driverLimited public transitRural or remote locationTransportation cost concernsUnreliable transportation

Other Transportation Barriers

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Emergency Contacts

Add one or more people CarePath may contact if there is an urgent problem.

Emergency Contact #1

Full NamePhone NumberRelationship

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Driver Preferences

These preferences can help coordinators make safe and comfortable ride assignments.

Preferred DriversDrivers to Avoid

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Other Things We Should Know

Share anything else that may make transportation safer, easier, or more comfortable.

Additional Notes