SOCIAL SECURITY # Spouse, Parent, or Legal Guardian Information & Emergency Contact info CELL # CLAIM # SECONDARY INSURANCE SUBSCRIBER S NAME
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- Sharyl Lawrence
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1 Patient Information PATIET S LEGAL AME BIRTH DATE SOCIAL SECURITY # AGE MARITAL STATUS Married Single MAILIG ADDRESS SEX Widowed CITY HOME # STATE Divorced Separated ZIP Do we have permission to leave a message on your phone? Text or appointment reminders? Y F M Y Who can we thank for referring you to OrthoRehab? Spouse, Parent, or Legal Guardian Information & Emergency Contact info AME RELATIOSHIP BIRTH DATE SEX F M PLACE OF EMPLOYMET OCCUPATIO In case of emergency, please contact: HOME # Relationship: Accident Insurance Information PLEASE COMPLETE: Work Related Y ACCIDET ISURACE Auto Accident Y Other Accident Y CLAIM # ADJUSTER S AME & PHOE UMBER DATE OF ACCIDET DESCRIBE Health Insurance Information PRIMARY ISURACE SECODARY ISURACE SUBSCRIBER S AME SUBSCRIBER S AME BIRTH DATE OF POLICY HOLDER BIRTH DATE OF POLICY HOLDER Additional Information PLACE OF EMPLOYMET OCCUPATIO WORK ADDRESS FAMILY PHYSICIA REFERRIG PHYSICIA I understand that should I default on payment of this account and collection agency services are required, all costs of collection including attorney fees will be added to the balance of said account. SIGATURE DATE PLEASE PRESET YOUR PHOTO ID & HEALTH ISURACE CARD(S) TO OUR FROT DESK PERSOEL
2 Medical History AME: Please mark the areas of your pain here: AGE: HEIGHT: WEIGHT: WHAT EASES YOUR PAI? WHAT MAKES YOUR PAI WORSE? WHAT ARE YOUR GOALS I PHYSICAL THERAPY? HAVE YOU HAD PREVIOUS TREATMET FOR THIS PROBLEM? PLEASE SPECIFY: PT CHIROPRACTIC OTHER HAVE YOU HAD AY OF THE FOLLOWIG TESTS? X-RAY CT SCA MRI EMG Please mark any of the following past and current conditions that apply to you (be as thorough as possible): CODITIO YES O Allergies Anemia Anxiety Arthritis Asthma Autoimmune Disorder Cancer Cardiac Conditions Cardiac Pacemaker Chemical Dependency Circulation Problems Currently Pregnant Depression Diabetes Please explain any of the above marked Yes and describe any additional conditions or precautions: CODITIO YES O Dizzy Spells Emphysema/Bronchitis Fibromyalgia Fractures Gallbladder Problems Headaches Hearing Impairment Hepatitis High Cholesterol High/Low Blood Pressure HIV/AIDS Incontinence Kidney Problems Metal Implants CODITIO YES O MRSA Multiple Sclerosis Muscular Disease Osteoporosis Parkinsons Rheumatoid Arthritis Seizures Smoking Speech Problems Strokes Thyroid Disease Tuberculosis Vision Problems Injury a result of a fall in the past year? YES O Have you had two or more falls in the last year? YES O Please describe all surgeries or hospitalizations (continue on back side if necessary): SURGERY TYPE: DATE (mm/yyyy): Please list all medications you are currently taking (continue on back side if necessary): MEDICATIO DOSAGE FREQUECY ROUTE REASO TAKIG SIGATURE: DATE:
3 Policy COSET TO USE AD DISCLOSURE OF PROTECTED HEALTH CARE IFORMATIO FOR TREATMET, PAYMET AD HEALTH CARE OPTIOS I understand that: As part of my health care, Orthopedic Rehab Inc. originates and maintains health records describing my health records describing my health history, symptoms, examinations, diagnoses and treatment. The use and disclosure of my protected health information (PHI) by Orthopedic Rehab Inc. is necessary in order to provide my medical care, and is also necessary for Orthopedic Rehab Inc. to obtain payment for my treatment and to carry out the practice s health care operations. I have the option to receive a copy of Orthopedic Rehab Inc. s otice of Privacy Practices which provides a more complete description of the use and disclosure of my health information, and that I have the right to review that otice prior to signing this consent. I also understand that Orthopedic Rehab Inc. reserves the right to change the otice and its privacy practices at any time and that if I request, Orthopedic Rehab Inc. will mail me a copy of any revised otice prior to its implementation. I give Orthopedic Rehab Inc. permission to talk to the following person/ people regarding my account and health information: AME: RELATIOSHIP TO PATIET: CACELLATIO AD O SHOW POLICY Your appointments are reserved especially for you and are very important to the OrthoRehab team. We understand that sometimes schedule changes are necessary and therefore, we respectfully request at least 24 hour notice for cancellations or rescheduling of appointments. Because of the busy nature of our office, 24 hour notice allows us time to offer your appointment to another patient. Missed scheduled appointments, without providing 24 hour advance notice, will be charged a $25 fee. ASSIGMET OF BEEFITS AD ISURACE DISCLAIMER I authorize my health insurance to make payment of medical benefits directly to Orthopedic Rehab Inc. I understand that I am liable for any charges incurred should my insurance or the liable party s insurance deny payment for AY reason. Although Orthopedic Rehab Inc. contracts with most insurance providers, they bill my insurance as a courtesy to me. I will provide all pertinent and related insurance information, including any accident, automobile, liability, and or health insurance. Orthopedic Rehab Inc. reserves the right to lien patient recoveries from legal or insurance settlements for unpaid charge when permitted by law. Orthopedic Rehab Inc. will not bill attorneys for any claims. I am responsible for knowing what my medical and outpatient physical therapy benefits are. I agree to pay any co-payments, co-insurance, and deductibles at the time of service. I understand that should my balance exceed 90 days, a finance charge will begin to accrue. Orthopedic Rehab Inc. will arrange a payment plan and/or assist me with Care Credit, when necessary. Unless payment arrangements are made with Orthopedic Rehab Inc., past due balances will be sent to an outside collections agency. I understand that should I default on payment of my account and collection agency services are required, all costs of collection including attorneys will be added to the balance of my account. PATIET OR GUARATOR SIGATURE DATE
4 eck Index ame: Date: This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem. PAI ITESITY 0 - I have no pain at the moment. 1 - The pain is very mild at the moment. 2 - The pain comes and goes and is moderate. 3 - The pain is fairly severe at the moment. 4 - The pain is very severe at the moment. 5 - The pain is the worst imaginable at this moment. PERSOAL CARE 0 - I can look after myself normally without causing extra pain. 1 - I can look after myself normally but it causes extra pain. 2 - It is painful to look after myself and I am slow and careful. 3 - I need some help but I manage most of my personal care. 4 - I need help every day in most aspects of self care. 5 - I do not get dressed, I wash with difficulty and stay in bed. SLEEPIG 0 - I have no trouble sleeping. 1 - My sleep is slightly disturbed (less than 1 hour sleepless). 2 - My sleep is mildly disturbed (1-2 hours sleepless). 3 - My sleep is moderately disturbed (2-3 hours sleepless). 4 - My sleep greatly disturbed (3-5 hours sleepless). 5 - My sleep is completely disturbed (5-7 hours sleepless). LIFTIG 0 - I can lift heavy weights without extra pain. 1 - I can lift heavy weights but it causes extra pain. 2 - Pain prevents lifting heavy weights off the floor, but I can manage if they are conveniently positioned (on a table). 3 - Pain prevents lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. 4 - I can only lift very light weights. 5 - I cannot lift or carry anything at all. READIG 0 - I can read as much as I want with no neck pain. 1 - I can read as much as I want with slight neck pain. 2 - I can read as much as I want with moderate neck pain. 3 - I cannot read as much as I want because of moderate neck pain. 4 - I can hardly read at all because of severe neck pain. 5 - I cannot read at all because of severe neck pain.
5 COCETRATIO 0 - I can concentrate fully when I want with no difficulty. 1 - I can concentrate fully when I want with slight difficulty. 2 - I have a fair degree of difficulty concentrating when I want. 3 - I have a lot of difficulty concentrating when I want. 4 - I have a great deal of difficulty concentrating when I want. 5 - I cannot concentrate at all. RECREATIO 0 - I am able to engage in all my recreation activities without neck pain. 1 - I am able to engage in all my usual recreation activities with some neck pain. 2 - I am able to engage in most but not all my usual recreation activities because of neck pain. 3 - I am only able to engage in a few of my usual recreation activities because of neck pain. 4 - I can hardly do any recreation activities because of neck pain. 5 - I cannot do any recreation activities at all. DRIVIG 0 - I can drive my car without any neck pain. 1 - I can drive my car as long as I want with slight neck pain. 2 - I can drive my car as long as I want with moderate neck pain. 3 - I cannot drive my car as long as I want because of moderate neck pain. 4 - I can hardly drive at all because of severe neck pain. 5 - I cannot drive my car at all because of neck pain. WORK 0 - I can do as much work as I want. 1 - I can only do my usual work but no more. 2 - I can only do most of my usual work but no more. 3 - I cannot do my usual work. 4 - I can hardly do any work at all. 5 - I cannot do any work at all. HEADACHES 0 - I have no headaches at all. 1 - I have slight headaches which come infrequently. 2 - I have moderate headaches which come infrequently. 3 - I have moderate headaches which come frequently. 4 - I have severe headaches which come frequently. 5 - I have headaches almost all the time. ECK IDEX SCORE: Index Score = [Sum of all statements selected / (# of sections with a statement selected X 5)] X 100
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Get Acquainted Questionnaire Tell Us About Your Child!
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Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Address: Street Apt. # City State Zip Code. Phone: ( ) - ( ) - ( ) - Home Mobile Work. Emergency Contact: ( ) - Name Relationship Phone
212-73 26th Ave Bayside, NY 11360 www.theptdoctor.com Tel: 718.747.2019 Fax: 718.767.6944 PATIENT NAME: (Full LEGAL NAME or as on your INSURANCE CARD) First Last Middle Initial Date of Birth (MM/DD/YYYY)
Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION
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Welcome to South 40 Dental! Tell Us About Yourself
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EYE ASSOCIATES OF MONMOUTH, LLC
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Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
Primary (First) Complaint and Location
Name: : File #: Case Type: Sex: Birth : Age: Social Security #: Address: Residence and Mailing City State Zip Code Home Phone: Mobile Phone: Email: Occupation: Employer: Work Phone: Marital Status: S M
How did you find out about our facility?
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PATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
Patient Information. Client/Responsible Party Signature: Date: Legal Representation (If applicable): Name: Signature:
Patient Information First Name: Middle Name: Last Name: Address: Apt/Unit: City: State: Zip: Date of Birth: / / Gender: Last 4 of Social Security #: Home Phone #: Cell #: E-Mail: Emergency Contact: Phone#:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
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CHISHOLM TRAIL ALLERGY AND ASTHMA PHONE (817) /FAX (817) DUTCH BRANCH ROAD, SUITE 200, FORT WORTH, TX
Today s Date: New Patient Registration and Medical History Patient Name: Nick Name: Address: Apt/Lot: City: State: Zip Code: Home Phone: Cell phone: Email: Is it ok to leave messages on the phone numbers
Back and Neck Pain Questionnaire
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Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
Patient Label. Insurance Information Primary Insurance: ID#: Secondary Insurance: ID#:
*BN7630* BN7630 Name: Home Phone: Address: Cell Phone: DOB: Age: Sex: q Male q Female Emergency Contact: Phone #: Insurance Information Primary Insurance: ID#: Secondary Insurance: ID#: Current Condition
Notto Chiropractic Health Center Patient Information
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Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
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Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
NEW PATIENT CHIRO OR PT: PATIENT INFORMATION:
FOR OFFICE USE ONLY: Patient Number: Doctor: Insurance: Emp. Initials: NEW PATIENT CHIRO OR PT: PATIENT INFORMATION: **Please give your Driver s License and insurance card to the front desk to copy for
WEBSTER CHIROPRACTIC CARE
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Kish Chiropractic 320 West Main Street Mount Horeb, WI
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