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Secure intake
Purser Wellness
New Patient Intake & Agreements
Four short sections: your details, key health information, optional symptoms and testing, then agreements and signature. Short answers are fine.
RequiredPatient details, reason for visit, allergies, medical history, policies, and signature.
OptionalMedications, supplements, symptoms, and previous testing.
No patient account
No lab uploads
Full PDF download
Review before sending
The final review page lets you return to any section and make changes.
Send once and download
The completed PDF goes to the Purser Wellness office. You may download the same full PDF.
Do not use this form for an emergency
For severe or urgent symptoms, call 911 or seek immediate medical care. This form is not monitored for emergency messages.
Required section
Patient Information
Final review
Review your intake before sending
Use Edit to return to any section. Optional sections marked “Not provided” are allowed.
Final submission
Submitting sends the completed PDF to Purser Wellness. Do not close this page until you see the confirmation screen.
Submission complete
You're all set.
Your intake was securely delivered to the Purser Wellness office. Your complete patient copy is ready to download below.
Office copy received
The office received the complete intake with a staff quick-summary page to make review easier.
Download your copy
Your patient copy contains the complete answers, agreements, and signature record you submitted.
Labs stay separate
If the office needs labs, genetic reports, or other records, continue using the separate secure process provided by Purser Wellness.
Save your completed intake
The PDF is available in this open tab only. Download it now if you want a personal copy.
Your answers have been cleared from the form.
The downloadable PDF remains available only until you start a new intake or close this tab.
The downloadable PDF remains available only until you start a new intake or close this tab.
Purser Wellness801-796-7667info@danpursermd.com