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Cedarwood/Intake/Sarah Chen

Patient intake

Sample intake submission — Sarah Chen · 9:30 AM appointment

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P-2087 · Annual physical · 9:30 AM

Sarah Chen

DOB 1991-04-12·Submitted Apr 30, 2026 at 7:14 AM·Intake complete

Contact details

Address82 Linden Ave, Apt 3B, Brooklyn, NY 11215
Phone+1 (917) 555-0144
Emailsarah.chen@protonmail.com
Emergency contactMarcus Chen · spouse · +1 (917) 555-0188
Preferred pharmacyCVS · 7th Ave & 9th St, Brooklyn

Medical history

  • Asthma · diagnosed 2009 · controlled
  • Hypothyroidism · diagnosed 2017
  • No prior surgeries

Current medications

MedicationScheduleSince
Levothyroxine 75mcgDaily, morning2017
Albuterol HFA inhalerAs needed2009

Allergies

SubstanceSeverityReaction
Penicillinmoderaterash, hives
Tree nutssevereanaphylaxis · carries EpiPen

Insurance

CarrierAetna PPO
PlanAetna Choice POS II
Member IDW-318-44-9012
GroupGRP-29401
EligibilityVerified · effective 01/01/2026

AETNA · PPO

Aetna Choice POS II

MEMBER

W-318-44-9012

SARAH CHENEFF 01/01/2026

Front of card uploaded Apr 30, 7:11 AM

Photo ID

DocumentDriver License (NY)
Number···-···-734
Expires08/2031
CapturedApr 30, 7:11 AM

Consents

  • Notice of Privacy Practices (HIPAA)

    Signed Apr 30, 7:13 AM

  • General consent to treat

    Signed Apr 30, 7:13 AM

  • Telehealth consent

    Signed Apr 30, 7:13 AM

  • Financial responsibility

    Signed Apr 30, 7:13 AM

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