INSURANCE... ACCIDENT INFORMATION PATIENT CONDITION _.
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1 WELCOME 3 LOCATIONS TO SERVE YOU BETTER! PINES WEST CHIROPRACTIC EAST SIDE CHIROPRACTIC MARTINEZ CHIROPRACTIC Pines Blvd., Suite Biscayne Blvd S.W. 137 Ave., Ste 108 Miami, FL Miami, FL Miami, FL PATIENT INFORMATION Patient: :..:., -"" Address: '--- City: State: Zip Code:...:..,_...:... Sex: OM OF Age: DOB: 0 Single D Married D Widowed D Divorced Patient SS No. Occupation: Employer Employer Phone No. Employer Address: :-,...:... Spouse's Name: Birthdate: ,-:..-...:..: Patient SS No. Occupation: ,:.::...:...::. : Spouse's Employer:.:..._~-~:...:--: Primary Care Physician: Whom may we thank for referring you: - Phone Number: ----'-:---..::::._~-=..:..-'----' ,.-,--"'-::,..--,:---:--:--- PHONES NUMBERS Home: Work: Ext: Best time to call Cell Phone: IN CASE OF EMERGENCY Name: Relationship: Home#: Work: INSURANCE ACCIDENT INFORMATION Who is responsible for this account? :-'----'=-''---':---'---~ Relationship to Patient ::-::-~-=-:-:-=-=----=-:-:---=~ Insurance Co. Name ~----=--?-7:"+-:+---:=-:-:----:~ Group or Card No ,...,...-=-,...-=-+- Is Patient covered by additional insurance D Yes Subscriber's Name Birthdate SS No. ~,-,---...,..,..--,-,...,.,-:,---,--- Relationship to Patient ----~-----::..,.--~-::-~..:...:,:..,...:.:.., Insurance Co. Name -----:--""':-"--.-:---:-..:., -~~-7----:-=-:-:----- lnsurance I.D. No ;..,--=...:~...:....:_...:...;_;..:---:---' Is condition due to an accident? DYes D No Type of Accident? D Auto D Work D Home 0 Other Explain Other: If yes, please tell our front office and fill out correct accident form in addition to this form. PATIENT CONDITION _. Reason for Visit: Preventive health check up: D Yes 0 No When did your symptoms appear? Is condition getting progressively worse? D Yes D No 0 Unknown Mark an x on the picture where you continue to have pain, numbness or tingling Rate the severity of your pain on a scale of 1 (least pain to 10 (server pain) Type of Pain: D Sharp D Dull D Throbbing 0 Numbness 0 Aching D Shooting D Burning D Tingling D Cramps D Stiffness D Swelling 0 Other How many days in the last week did you feel the pain? D Is it constant or D Occasional Does it interfere with your D Work D Family Life D Sleep D Recreation D Exercise Activities or movements that are painful to perform D Sitting D Standing D Walking D Bending D Lying Down D Driving Do~ u s~erkoma~otherh~~cond~on~ ~---- PAST HEALTH HISTORY Please Check and Describe: Major Surgery/Operations: D Appendectomy D Tonsillectomy D Gall Bladder D Hernia D Back Surgery 0 Broken Bones 0 Other Car accidents, falls, i~uries: ~ Hosp~al~ationiDtherThanAbove): Previous Chiropractic Care: D None D Doctor's Name & Approximate of Last Visit _ Drugs You Now Take: D Nerve Pills D Pain Killers/ Muscle Relaxers 0 Blood Pressure Medicine D Insulin OOther
2 Below are a list of diseases which may seem unrelated to the purpose of your appointment. However the questions must be answered carefully as these problems can affect your overall course of chiropractic care. CHECK ANY OF THE FOLLOWING DISEASE YOU HAVE HAD OR CURRENTLY HAVE: 0 Pneumonia 0 Rheumatic Fever D Polio 0 Tuberculosis 0 Whooping Cough 0 Anemia 0 Measles 0 Chemical Dependency OAicoholism D Mumps 0 Small Pox 0 Chicken Pox 0 Diabetes 0 Cancer D Heart Disease 0 Thyroid 0 Asthma D Aids/H.I.V. 0 Influenza 0 Pleurisy 0 Arthritis 0 Epilepsy 0 Mental Disorders 0 Lumbago 0 Eczema 0 Stroke 0 Osteoporosis 0 Weak Immune System 0 Subluxations D Pacemakers 0 Multiple Sclerosis 0 Psychiatric Care D Hepatitis 0 Hernia 0 Carpal Tunnel Synd. 0 Repetitive Strain Synd. CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST SIX MONTHS: MUSCULO-SKELETAL CODE 0 Low Back Pain 0 fla~n Between Shoulders 0 Neck Pain 0 Arm Pain 0 Joint Pain/Stiffness D Shoulder Pain 0 Knee Pain 0 Hip Pain 0 Hand/Wrist Pain 0 Foot/Ankle Pain GENERAL CODE 0 Fatigue 0 Allergies D Loss of Sleep 0 Fever D Headaches C-V-R CODE 0 Chest Pain 0 Shortness of Breath 0 Blood Pressure D Irregular Heartbeat 0 Heart Problems 0 Lung Problems/Congestion 0 Varicose Veins 0 Ankle Swelling 0 Stroke GASTRO-INTESTINAL CODE 0 Poor/Excessive Appetite D Excessive Thirst D Frequent Nausea D Vomiting D Diarrhea 0 Constipation 0 Hemorrhoids 0 Liver Problems 0 Weight Trouble 0 Abdominal Cramps 0 Gas/Bloating After Meals 0 Heartburn 0 Black/Bloody Stool 0 Colitis GENITO-URINARY CODE D Bladder Trouble 0 Painful/Excessive Urination 0 Discolored Urine MALE/FEMALE CODE 0 Menstrual Irregularity 0 Menstrual Cramps 0 Vaginal Painjlnfection 0 Breast Pain/Lumps 0 Prostate/Sexual Dysfunction 0 Venereal Disease 0 Other Problems NERVOUS SYSTEM CODE 0 Nervous 0 Numbness 0 Paralysis 0 Dizziness 0 Forgetfulness 0 Confusion/Depression 0 Fainting 0 Convulsions 0 Cold/Tingling Extremities 0 Stress EENTCODE 0 Vision Probers 0 Dental Problems 0 Sore Throat 0 Ear Aches 0 Hearing Difficulty 0 Stuffed Nose FAMILY HISTORY The following members have the same or sim1lar problems as I do: 0 Mother 0 Father 0 Brother 0 Sister 0 Spouse 0 Child FEMALES ONLY When was your last menstrual cycle? Are you pregnant? 0 Yes 0 No 0 Not Sure EXERCISE WORK ACTIVITY HABITS D None 0 Sitting 0 Smoking D Moderate 0 Computers 0 Alcohol 0 Daily 0 Standing O Coffee/Caffeine Drinks 0 Heavy 0 Light Labor 0 High Stress Level 0 Heavy Labor Packs/Day Drinks/Week Cups/Day What is most important in your Doctor/Patient relationship? What are your health goals? 0 pain relief only 0 correct my health problem Signature
3 AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION I authorize Martinez Chiropractic Center and any member of its staff to call, leave voice mail messages and\ messages and disclose Protected Health Information (PHI) pertaining to me, including but not limited to medical information, such as test results, procedures results, appointment reminders, or any other PHI related to my treatment to the following numbers: Home Number Work Number Cell Phone Number Appointment Reminders: Text Message Cell Phone Company: No Reminder All reminders are sent approximately 24 hours prior to your appointment. I authorize Martinez Chiropractic Center and any member of its staff to fax my (PHI), including medical information needed for my treatment to the following fax number:. I authorize Martinez Chiropractic Center and any member of its staff to disclose my (PHI), including test results to the following individuals: Patient Signature
4 RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGMENT FORM I, have received a copy of Martinez Chiropractic Center Notice of Patient Privacy Practices. INFORMED CONSENT FORM I, hereby request and consent to the performance of chiropractic treatments and other chiropractic/medical procedures, including various forms of physical therapy and diagnostic x-rays by Martinez Chiropractic Center. This consent is extended to other licensed chiropractic Physicians, Chiropractic assistants or licensed Massage Therapists, who now or in the future, are employed by, working with or associated with this office. I certify that I have had the opportunity to discuss, with the doctor of Chiropractic and/or other office personnel, the nature and purpose of the care that is being provided. I understand that the results are not guaranteed. Further, I have been informed and I understand that, as in the practice of any of the healing arts, in the practice of Chiropractic, there are some risks to treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I also understand that the doctor, who has explained all of these things to me, is not expecting to be able to anticipate and explain all the risks and complications. I will rely on the doctor to exercise appropriate judgment during the course of care, based on the facts known at this time, and in my best interest. My signature below certifies that I have read, or have had read to me the above consent. I also certify that I have had the opportunity to ask questions and options to care have been explained. By signing this consent form, I agree to the care being provided to me for the entire course of treatment for my present condition(s) and for any future condition(s) for which I seek treatment. My signature certifies that I have read and agreed to what has been stated above. Patient Signature
5 No Accident Form I, am seeking care from Martinez Chiropractic Center. The treatment is not due to a work related injury, automobile accident, or slip and fall. AUTHORIZATION I hereby authorize payment of benefits due to me from my insurance company and/or attorney to be made directly to Martinez Chiropractic Center. I further authorize the release of any medical records required by my insurance carrier. I fully understand that I am financially responsible for any charges covered by this authorization to Martinez Chiropractic Center. In the event that it becomes necessary to institute litigation over the non-payment of our fees, the cost and legal expenses incurred therein are that of the patient. Insurance Certification This is to certify that I, have presented any and all information regarding my health insurance plan(s). The only health insurance policy in effect is: Name of Insurance Co. Insured s Name Relationship with Insured ID# Group# My signature certifies that the information I have filled in above is accurate, and that I am not seeking care due to an auto accident, work injury, or slip & fall nor do I have an open or pending case. Patient s Signature Print Patient s Name
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ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Name: (Last) (First) Name you prefer to be called: Patient Address for shipping: (No PO Boxes)
AMI: Intake /Chiro 1 Patient Information Form Name: (Last) (First) (MI) Name you prefer to be called: Patient Address for shipping: (No PO Boxes) City: State: Zip: Phone: Cell: E-mail: Birthdate: SS #:
Street address: City: State: Zip: Address:
Patient Information: Date: First name: Middle initial: Last name: Date of Birth: SSN# Best phone number to contact you at: Home Work Mobile How did you hear about us? Referral by: Street address: City:
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
PLEASE NOTE: This file must be saved to your desktop before and after completing!
PATIENT INFORMATION PLEASE NOTE: This file must be saved to your desktop before and after completing! Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Insurance. Patient Family Information. Patient Condition
Welcome to Amarillo Family Wellness Group In order to serve you best we would like to know more about you and your health history. Please print clearly and fill this out completely prior to your appointment
PATIENT PERSONAL / CONFIDENTAL DATA
PATIENT PERSONAL / CONFIDENTAL DATA Address: City: State: Zip Code : H. Phone: W. Phone: Cell Phone: Date of Birth: Age: Sex: M F Marital Status: M S D W Email Address: Social Security # Name of Spouse:
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
New Patient Intake Forms. Patient Data Date. Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other. First Name Middle Initial Last Name
New Patient Intake Forms Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address Line City State Zip Code Home Phone ( ) -
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT Patient (First) (Middle) (Last) Address City State Zip E-mail address Home Phone # Cell Phone # Would you like an appointment reminder? Text( ) Call(
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
th Place, Third Floor, Vero Beach, FL, Tel No , Fax:
We thank you for choosing our facility for your wellness needs. It is very important to us to deliver the best possible care to you and to all our clients. In trying to do so, we ask that you follow the
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
CORNERSTONE PAIN MANAGEMENT
SECONDARY INSURANCE PRIMARY INSURANCE CORNERSTONE PAIN MANAGEMENT PATIENT INFORMATION First Name: Dr. Mr. Mrs. Ms. Miss MI: Last Name: Social Security: Age: Date of Birth: Gender: Address: City: State: