Patient Intake &
Records Submission

Upload Patient Records

To provide you with the best possible care, we ask that all patients submit the following information and records prior to their appointment. Completing this early allows our doctors to review your case in advance, determine if any additional imaging or labs are needed, and potentially move you to an earlier appointment or surgery date.

Your Information

Please confirm your contact details and provide an emergency contact.

Please enter your first name
Please enter your last name
Please enter a valid email
Please enter your phone number
Please enter your date of birth
Please select a gender identity
Please select a provider
Emergency Contact Someone we can contact on your behalf if needed.
Please enter the emergency contact's name
Please enter a phone number
Please enter the relationship

Address & Insurance

Please provide your mailing address and insurance information.

Please enter your street address
Please enter your city
Please enter your state or region
Please enter your zip code
Please enter your country
Insurance Information Your insurance carrier and member ID number.
Please enter your insurance carrier
Please enter your insurance ID
A clear photo or scan of the front of your insurance card.
Click to choose a file or drag & drop Browse
Please upload the front of your insurance card
A clear photo or scan of the back of your insurance card.
Click to choose a file or drag & drop Browse
Please upload the back of your insurance card

Identity Verification

Please upload a government-issued ID and a recent headshot for patient identification.

A photo or scan of your driver's license, passport, or other government-issued photo ID.
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Please upload your government-issued ID
Please upload a recent photograph of your face taken against a plain background. Ensure that the photo:
  • Shows only your face with a neutral expression
  • Is clear and well-lit, with no shadows or obstructions
  • Is intended for identification purposes on medical records or patient access cards
This helps healthcare providers accurately recognize you and ensure seamless access to your records.
Click to choose a file or drag & drop Browse
Please upload a clear headshot photo

Medical Records

Please upload your recent imaging and lab results.

Please Submit One Combined PDF Per Category If you have multiple imaging reports or lab results, please combine each category into a single PDF before uploading. Separate files significantly slow down the review process.
Upload all imaging reports as a single combined PDF. Includes radiology reports, MRI, CT, X-ray, and ultrasound results.
Click to choose a file or drag & drop Browse
Please upload your imaging records as a single PDF
Upload all lab results as a single combined PDF. Includes bloodwork, hormone panels, and any other lab reports.
Click to choose a file or drag & drop Browse
Please upload your lab results as a single PDF
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Records Submitted Successfully

Thank you. Your records have been securely sent to the ESSE Care team. Your provider will review them ahead of your appointment and reach out if anything additional is needed.

All records must be submitted at least 1 week before your appointment. Incomplete submissions may result in rescheduling.

Privacy Note: All information submitted is kept strictly confidential and secured in compliance with HIPAA regulations.