**PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax:
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1 Helpful Telephone Numbers Pre-Registration Hospital Billing (NWH) Physician/Provider Billing (MGPO) Web Address nwh.org Pre-Registration Please call up to 7 days prior to your appointment to pre-register for this appointment. This call typically takes a few minutes. Please have your insurance information available. Insurance plans vary in their requirements. Your plan may require a potential referral, authorization, or out -of-pocket payment for this visit. Preregistration is available Monday-Friday from 8 AM 5 PM at , or you can pre-register at our website: Parking There is plenty of free parking all around the building. You can enter through the front or back entrance. There is also handicapped parking in the back of the building. **PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax: Patient Instructions Our patient hours are Monday through Friday 8:00 AM to 5:30 PM. Our phone hours are Monday through Friday 8:00 AM to 4:30 PM. We ask that you arrive 30 minutes prior to your appointment time in order to prepare you for your visit. Please print the Spine Center New Patient Packet (attached or located on our website at For your comfort during the exam, you may want to bring shorts and a t -shirt or sports bra. We require that patients refrain from using creams, scented lotions or perfumes on the day of their visit. MRI s or X-rays If you have had any recent MRIs done in the year prior to your visit and they were not performed at NWH or MGH, please bring the images and reports to your appointment. Insurance Referrals If your insurance requires a referral to see a specialist, you are responsible for obtaining that referral from your Primary Care Physician prior to your appointment and ensuring that we have received it. If the department has not received the referral, your appointment will be cancelled or you will be asked to sign a waiver stating that you are aware that you are being seen without a referral and no further appointments or diagnostic tests will be scheduled. Please fax all referrals to Co-Payments If your insurance requires a copayment, it is due at the time of your visit. We accept payment in the form of a credit card. Full payment for self-pay visits and procedures, such as prolotherapy and acupuncture are due at the time of the visit. The Spine Center is a hospital based outpatient clinic. It is standard to receive one bill representing the physician charges from their billing provider (MGPO) and another bill representing the hospital/facility charges from NWH. For questions regarding the physician s bill, please call For questions regarding the hospital bill, please call
2 Label or Spine Center/Newton-Wellesley Hospital 159 Wells Ave Newton, MA Name: Date of Birth: Spine Center Questionnaire Are you Right Left Handed? When did your current problem start? / / (month/day/year) What is the main problem(s) for which you are seeking treatment at the Spine Center? _ Please list prior spine surgeries, if any (date and type): Please indicate how your present symptoms began? Auto accident While working Other My symptoms have: remained the same become more severe become less severe Which of the following best describes your pain ratio? 100% back or neck 100% leg or arm 75% back or neck and 25% leg or arm 50% back or neck and 50% leg or arm 25% back or neck and 75% leg or arm Circle your current pain: (no pain) (severe, Emergency Room) Please mark location of your pain: How would you describe your pain? burning sharp electric-like pins/needles shooting stabbing aching dull throbbing other How often do you have your pain? Constant, every minute of the day Intermittent and occurring daily Intermittent and occurring on most days Infrequent How do the following affect your pain (please check one for each item)? Increase Decrease No change Walking Sitting Standing Rising from sitting Bending forward Lying on your side Please check the approximate amount of time you can perform the following activities: unable 15 minutes 30 minutes 45 minutes 1 hour indefinitely Sit Stand Walk 2
3 Please list below medications that you have tried for your current pain: Please check all treatments you have tried for your current pain: Treatment Dates No Relief Moderate Relief Physical Therapy Excellent Relief Injections (epidural, facet, etc.) Chiropractic Please list all diagnostic studies that you have had for this problem (indicate approximate dates): MRI/CT: X-Rays: EMG: CURRENT MEDICATIONS (please fill out the dosages and how often taken): ALLERGIES: Please check all items you feel are currently applicable to you: leg weakness difficult or frequent urination genital numbness fever or chills severe nighttime pain recent infections feeling depressed weight loss arm weakness arm or leg numbness decreased appetite anxiety fatigue poor sleep headaches double vision dizziness hoarse voice difficulty hearing swollen glands swollen joints rash chest pain shortness of breath leg swelling abdominal pain nausea stomach ulcer acid reflux blood in stool black stool bowel accidents blood in urine prostate enlargement erectile problems abnormal bruising thyroid problem muscle aches Have you experienced significant stress this past year? Please explain: Have you had any of the following health problems (please check all that apply)? High blood pressure Diabetes Kidney disease Heart disease Osteoporosis Liver disease Bleeding Cancer, please specify Do you have any pending health related litigation? Yes No What is your occupation? Are you currently working? Yes No If yes, then how many hours per week? If you are currently unemployed, indicate how long you have been off work: Are you Single Married Widowed Separated Divorced? Number of children? Do you smoke? Nonsmoker Current smoker Quit (date: ) Do you drink alcohol? No Yes (drinks/week: ) What kind of exercise do you do? How many days per week and for how long per session? Is there a history of low back or neck pain, arthritis in your family? Patient Signature: Date: 3
4 NEWTON-WELLESLEY HOSPITAL NEWTON, MASSACHUSETTS SPINE CENTER EFFECTIVE DATE: POLICY TYPE: ADMIN 10/30/12 CLINICAL DEPARTMENTAL X_ SPINE CENTER CANCELLATION, LATE, NO SHOW AND WAIT LIST POLICY PURPOSE: The purpose of this policy is to ensure that all patients are scheduled appropriately should they cancel, fail to appear for their appointment or request placement on a wait list. SCOPE: This policy applies to the Spine Center in the Department of Rehabilitation Services. POLICY & PROCEDURE STATEMENT: All Spine Center staff and patients will be made aware of this policy. Staff will be expected to schedule visits accordingly. A record of cancellations and no shows is maintained within the patient's scheduling history. DEFINITIONS: N/A PROCESS: I. CANCELLATION: A patient may call any time up to the day before the scheduled appointment to cancel an appointment. A Monday appointment must be cancelled no later than the Friday before. A patient may reschedule a cancelled appointment. II. III. IV. LATE: A patient who is more than 15 minutes late for an evaluation or 10 minutes late for a follow up appointment without prior notification of staff may need to be rescheduled. This decision will be up to the discretion of the individual physician and may require the patient to wait until scheduled patients are seen. NO SHOW: A patient who attempts to cancel an appointment the day of the appointment except in extenuating circumstances is considered a NO SHOW. Three "NO SHOW S" over the total of a year will prevent any further scheduling within the Spine Center. The patient will be referred to at least 2 other programs that will meet their needs. WAIT LIST: When patients request placement on a wait list, their name, the nature of their chief complaint, any extenuating circumstances, and their temporarily assigned appointment date will be logged. Every effort to accommodate an earlier appointment time attempted based upon acuity and time to next appointment. REFERENCES: N/A ORIGINATOR: SPINE CENTER, DEPARTMENT OF REHABILITATION SERVICES ORIGINATION DATE: 07/01/02 SPONSOR: Spine Center Coordinator COLLABORATOR(S): N/A REVIEWED: July 2006 REVISED: July 2015 PLEASE SIGN OTHER SIDE 4
5 CROSS-REFERENCE: N/A APPROVAL BY: Medical Co-Director, The Spine Center; Director of Ambulatory Services CANCELLATION: N/A KEY SEARCH WORDS: cancellation policy, appointments, late, no show, wait list, cancellation, spine, spine center ATTACHMENTS: N/A Acknowledgement of Receipt of Spine Center Cancellation, Late and No Show Policy: The goal of the staff at the Spine Center is to accommodate patient requests for an appointment to see their provider in a timely manner. This can be a challenge when appointments are missed or canceled at the last minute. The staff keeps a list of patients waiting for an appointment. In order to effectively use this list, the clinic needs 24 hours to contact patients and offer them a more convenient appointment time. In an effort to improve this process, the Spine Center has developed a policy for patients to use as a guide when it is necessary to cancel or change an appointment. We do understand that there are extenuating circumstances and we will handle these on a case by case basis. Please review the policy and acknowledge below that you have received a copy. I have received and reviewed a copy of the Spine Center Policy. Signature: Date: 5
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NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
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:
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM First Name MI Last Preferred Name Date of Birth / / Age Gender Patient/Guarantor SS# - - Email Address Martial Status Single Married Other Street Address City State Zip Code Profession
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE Today s : Patient Name: DOB: Race White/Caucasian Black/African American Asian Native American Alaskan Native Native Hawaiian Pacific Islander Other: Preferred Language:
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
9834 Genesee, Suite 223B La Jolla, CA Phone Fax
PATIENT HEALTH QUESTIONNAIRE (Page 1) 9834 Genesee, Suite 223B La Jolla, CA 92037 Phone 858-277-7123 Fax 858-277-3470 ***Please fill out completely. Failure to do so may delay payment of your claim. Indicate
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
I choose not to specify
Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
New Patient Information
(Please Print) New Patient Information Name Address City/State/Zip Cell: Home: email: Social Security # Birthdate Age Male Female Occupation Employed by Wk ph. # Address City/State/Zip Number of Children
Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or