HomePatient Forms & PoliciesMaster Intake Acknowledgment
Required at Intake
Master Intake Acknowledgment
Single-page acknowledgment that you have reviewed the four core intake documents.
The full Master Intake Acknowledgment is provided as a PDF.
Use the Download PDF button above to read the complete document. You’ll review and sign this form through Jane, our practice-management system, when you schedule a visit as a new client.
If you’d like a copy of an earlier version, or if you have a question about anything in this document, email admin@bayoucitybreastfeeding.com. We won’t begin treatment until you’ve had the opportunity to review the documents and ask questions.
What this document covers
The Master Intake Acknowledgment is a short, single-page form that confirms you have reviewed the four core intake documents: the General Consent, the Notice of Privacy Practices, the Good Faith Estimate and Surprise Billing Notice, and the Payment-Related Consent. Signing the Master Intake Acknowledgment is how we record that you had the opportunity to review each document and ask questions before treatment.
How it fits with the other forms
This is one of the four core intake documents (along with the Notice of Privacy Practices, the Good Faith Estimate, and the Payment-Related Consent), plus the Master Intake Acknowledgment that confirms you have reviewed all four. New clients receive these through Jane, our practice-management system, when an appointment is scheduled.
Questions before you sign?
Email admin@bayoucitybreastfeeding.com or call (281) 305-0411. We’re happy to walk through any section with you before your first visit.
Ready to schedule?
When you book a visit, Jane sends you the intake documents and the consent for the service you’re scheduling. Request Appointment or call (281) 305-0411.