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. You can complete the form below or use our Patient Portal. Submitting 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.

First Name *

Please enter your first name

Last Name *

Please enter your last name

Email *

Please enter a valid email

Phone Number *

Please enter your phone number

Date of Birth *

Please enter your date of birth

Provider *

Please select a provider

Emergency Contact Someone we can contact on your behalf if needed.

Emergency Contact Name *

Please enter the emergency contact's name

Emergency Contact Phone *

Please enter a phone number

Relationship to Patient *

Please enter the relationship

About You

This information helps us provide you with the best possible care.

Gender Identity *

Please select a gender identity

Pronouns *

Please select your pronouns

Assigned Sex at Birth *

Please select assigned sex at birth

Sexual Orientation *

Please select an option

Marital Status *

Please select your marital status

Preferred Language *

Please select a language

Race *

Please select an option

Ethnicity *

Please select an option

Address & Insurance

Please provide your mailing address and insurance information.

Street Address *

Please enter your street address

Street Address Line 2

City *

Please enter your city

State / Region *

Please enter your state or region

Zip Code *

Please enter your zip code

Country / Region *

Please enter your country

Insurance Information Your insurance carrier and member details.

Insurance Carrier *

Please select your insurance carrier

Member ID / Certification Number *

Please enter your insurance ID

Policy / Group Number *

Please enter your Policy / Group Number

Insurance Card Image (Front & Back Same Image) * Take a photo or upload a scan of your insurance card with both the front and back included in one single image.

Click to choose a file or drag & drop Browse

Please upload one image showing the front and back of your insurance card

Identity Verification

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

Driver's License Number *

Please enter your driver's license number

Driver's License State *

Please enter the issuing state

Driver's License Expiration *

Please enter the expiration date

Government-issued ID / License * A photo or scan of your driver's license, passport, or other government-issued photo ID.

Click to choose a file or drag & drop Browse

Please upload your government-issued ID

Clear Identification Photo (Headshot) * 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

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.

Recent Imaging (MRI, X-rays, Ultrasounds, etc.) * Upload all imaging reports as a single combined PDF.

Click to choose a file or drag & drop Browse

Please upload your imaging records as a single PDF

Recent Labs * Upload all lab results as a single combined PDF.

Click to choose a file or drag & drop Browse

Please upload your lab results as a single PDF

Uploading... 0% Please do not close or refresh this page until the upload is complete.

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.

Patient Intake &
Records Submission

Upload Patient Records

Your Information

About You

Address & Insurance

Identity Verification

Medical Records

Education

Patient Resources

Partner Resources

About ESSE Care

Patient Intake &Records Submission

Upload Patient Records

Your Information

About You

Address & Insurance

Identity Verification

Medical Records

Education

Patient Resources

Partner Resources

About ESSE Care

Patient Intake &
Records Submission