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http://vitaliapdx.com/wp-content/uploads/2014/07/INTAKE-FORM...

Please provide us with your pharmacy’s information on the intake form below. Remember to update your pharmacy information if there are any changes. Please do not rely on your pharmacy to notify us before your prescription runs out. Call our front office or email your physician at least 48 hours before you run out of
your prescription is the best way to ensure your needs are met.

Или приемная информация / или информация для записи на прием
Просто в лоб!
Судя по перечисленным пунктам...
Тут дело не только в принимаемых лекарствах, как стало ясно.

Напр., приёма (консультации) у врача. Приёма в программу оказания услуг и т.п. Поступления (госпитализации) в клинику... Для выбора нужно лучше ознакомиться с переводимым текстом.

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Note added at 1 hr (2014-10-24 16:19:12 GMT)
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INTAKE PACKET
...
****Intake Requirements****:

Copy of: ____Birth Certificate
____Physical Examination
____Immunization Records
____Social Security Number
____Medicaid or Private Insurance Card (PLEASE COPY FRONT AND BACK OF CARD)
Sex Offender Registration, if applicable
Educational report(s)
Medication: if applicable
____ Two week supply of medication
____ Recent psychiatric or medicine review
____Authorization to administer psychotropic medication
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https://www.starr.org/sites/default/files/michigan_intake_pk...

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Note added at 1 hr (2014-10-24 16:20:46 GMT)
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**YOUTH AND ADOLESCENT INTAKE**
Legal Name: Date of Birth: / /
Legal Address:
City: State: Zip Code:
Home Phone: / / Cell Phone: / /
Social Security Number: / / (Required)
FAMILY
...
http://dianeburks.com/docs/youth-intake.pdf

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Note added at 1 hr (2014-10-24 16:21:41 GMT)
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Huron Valley Consultation Center
Intake Date ___________________ Ann Arbor, Michigan Case #_______________
****CHILD INTAKE INFORMATION****
Patient Name: ____________________________________DOB: __________________Age: ___________Sex: _______
Address: ___________________________________________________________________________________________
Street City State Zip
School:________________________________________________ Grade: _______
...
http://www.huronvalleyconsult.org/intake-child.pdf

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Note added at 1 hr (2014-10-24 16:23:00 GMT)
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Intake Forms

Please carefully review and complete the following forms prior to your child's **scheduled intake**. You will need to bring the completed forms with you to the **intake meeting**.

There are additional documents, items and pieces of information that you must bring with you to the intake meeting. Please carefully review the Intake Checklist for a list of these very important items.

Please contact us if you have questions or are in need of assistance.

Basic Information Forms & Authorizations

****Child & Family Intake Information— Information about the child, family and family care team.****
...
http://www.jaspermountain.org/program_forms.html