Intake Forms

We require that all potential patients complete all of our intake forms and request at least 2 years of medical history from prior providers to be sent to us. Once these are done, we will contact you to schedule your intake appointment. The process is the same for both local and out-of-state patients.

Lighthouse Complex Care of Delaware - Medical Intake Form

This form includes questions about current health and medical history which are critical to helping us understand your (or your child's) needs. This must be filled out completely and accurately before we can schedule your appointment.

Time to complete: approximately 30-45 minutes

Open Intake Form