Myofascial Treatment Center of Modesto Patient Information Sheet
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1 Myofascial Treatment Center of Modesto Patient Information Sheet Last Name First Name Middle Initial Mailing Address City State Zip Code / / Home Phone Number Date of Birth Age Female Male address Driver s License / / Social Security Number Cell Phone Number Married Single Separated Divorced Widowed Is your condition the result of a work injury? Is your condition the result of an auto accident? Yes No Date of injury Time of injury Date Last Worked Place of Injury Patients Employer Employer Phone Number PARENT/SPOUSE INFORMATION If you are a parent/spouse of the patient, complete this part of the form. If not, skip to Emergency Contact Information. Relationship to Patient Parent/Spouse Last Name Parent/Spouse First Name Mailing Address City State Zip Code / / Social Security Number Phone Number EMERGENCY CONTACT INFORMATION Relative whom we can contact in event of emergency. Relationship Home Phone Number Work Phone Number LEGAL INFORMATION If you are represented by an attorney for this injury, please complete this part of the form. If not, skip to insurance. Attorney Name Mailing Address City State Zip Code Work Phone Number Page 1 of 6 pages
2 INSURANCE INFORMATION Do you have insurance? Yes No Private Pay If so, what type of insurance do you have? PPO HMO Workman s Comp Primary Insurance Name Subscriber Name Insurance City State Zip Code Adjuster Insurance Group Number Identification Number Effective Date Percent of Coverage If you do not have secondary insurance, skip to Financial Agreement. Secondary Insurance Name Subscriber Name Insurance City State Zip Code Adjuster Insurance Group Number Identification Number Effective Date Percent of Coverage Financial Agreement, Assignment of Benefits and Authorization for Treatment I authorize treatment of the person named above and agree, irrevocably, whether signing as agent or as patient, that in consideration of the services to be rendered to the patient that I hereby individually obligate myself to pay the account in accordance with the regular rates and terms of the provider. I hereby give authorization for payment of insurance benefits directly to the provider named above, and any assisting physicians for services rendered. As required by law, you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations. Should the account be referred to an attorney or collection agency for collection, the undersigned agrees to pay actual attorney s fees and collection expenses. It is agreed that payments will not be delayed or withheld because of any insurance coverage or the pendency of claims thereon, and all proceeds of insurance are assigned to this office where applicable, but without their assuming responsibility for the collection thereof. (A copy of this assignment is as valid as the original.) Signature Date Release of Information The provider may disclose all or part of the patient s record to any person or corporation which is or may be liable under a contract to the provider or to the patient, family member, or the employer of the patient or the family member for all or part of the providers charge, including but not limited to, medical service companies, workman s compensation carriers, welfare funds, or the patient s employer. I further authorize my employer to release employment information to the provider or the provider s agents. Signature Date Page 2 of 6 pages
3 Is this the first time you have had this pain/complaint? How many episodes of you pain/complaint have required treatment? Have you been hospitalized or had surgery for this same or similar pain/complaint before? Please indicate your usual level of pain during the past week [0 for no pain, 10 for worst possible pain]. Did you see a health professional within seven days of the How long ago did your current episode begin? onset of your pain/complaint? Less than two weeks ago. Two weeks to less than eight weeks ago. Do you use tobacco? Eight weeks to less than three months ago. Three months to less than six months ago. Six months to twelve months ago. Do you chew? More than twelve months ago. Do you smoke? If you smoke, how often? Less than one pack a day. More than one pack a day. How physically demanding is your job? Include housework if you are not employed outside the home. How much have you been able to control (i.e. reduce/help) pain/complaint on your own during the past week? (0 for being able to reduce your pain, 10 for not being able to reduce it at all) During the last week how often have you taken medication for your pain/complaint? + times a day. Once or twice a day. Once every couple of days. Once a week. Not at all. Please indicate how depressed you have been feeling during the past week (0 for not depressed at all, 10 for extremely depressed). How anxious (e.g. tense, uptight, irritable, fearful, difficulty in concentrating/relaxing) have you been feeling during the past week? (0 for not at all, 10 for extremely anxious) If you had to spend the rest of your life with your condition as it is right now, how would you feel about it? Delighted Pleased Mostly satisfied Mixed Mostly dissatisfied Unhappy Terrible Page 3 of 6 pages
4 Have you ever received hand-on therapies before? Do you frequently suffer from stress? (i.e. Myofascial Release or Soft Tissue Therapy) Do you have diabetes? Do you have frequent headaches? Are you pregnant? Do you suffer from arthritis? Are you wearing contact lenses? Do you suffer from epilepsy or seizures? Do you suffer from joint swelling? Do you have varicose veins? Do you have osteoporosis? Do you bruise easily? Do you have any cardiac or circulatory problems Does your pain/condition limit your ability to sleep? Do you have high blood pressure? Have you ever had surgery? If, so are you taking any medication for this? What is the name of this medication? Do you have any contagious diseases? Have you had any broken bones? Do you have any allergies? What are they? Does your pain/condition increase with activity? Does your pain/condition cause difficulty with intercourse? Do you have any other medical conditions I should be aware of? Page 4 of 6 pages
5 Show the location of your pain/complaint by drawing the appropriate symbols on the figures below. Sharp and Stabbing Dull and Achy V V V V V Numbness / / / / / Pins and Needles Please take a moment to carefully read the following information and sign where indicated. If you have a particular medical condition or specific symptom, Myofascial Release/Soft Tissue Therapy may be contraindicated. A referral from your primary care provider may be required prior to treatment. Agreement I understand that the Myofascial Release/Soft Tissue Therapy I receive is provided for the purpose of relief of muscular tension and relaxation. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that Myofascial Release/Soft Tissue Therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that Myofascial Release/Soft Tissue Therapy practitioners are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe or treat any physical or mental illness, and that nothing said in the course of treatment should be construed as such. Because Myofascial Release/Soft Tissue Therapy should not be performed under certain medical conditions. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner s part should I forget to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Patient Signature Date Therapist Signature Date Consent for Treatment of a Minor By my signature below, I hereby authorize to administer treatment techniques to my child or dependent as they deem necessary. Parent/Guardian Signature Date Images for Medical Records With my signature, I (print name) give my consent to be photographed for medical record purposes. These photograph images will be used to accurately record progress and be used by the therapist, doctor and insurance representative. Images will be taken as needed to show progress in the chart. My signature does not give permission for publication or circulation other than in above mentioned circumstances. Patient Signature Date Date placed in chart Page 5 of 6 pages
6 Soft Tissue and Myofascial Treatment, Inc. Myofascial Treatment Centers Coffee Road, Suite 7 Modesto, California (209) Fax Cancellation/No Show Policy It is the policy of the Myofascial Treatment Center that scheduled appointments that are canceled with a 24 hour notice or more, there will be no charge. Appointments that are canceled with less than 24 hours will be charged at half the cost of the scheduled visit. No Show Appointments: if you have a scheduled appointment and you no show the appointment (do not come in for the appointment) and do not call you will be billed for the full cost of that visit. This includes workers compensation patients. Although we cannot bill workers compensation for your no show appointment we call and will bill you. Payment of Services Fee s affective January 1, 2019 Payment is to be made at time of visit or arranged in advance. Each office visit/treatment is $ A discount is given for payment at time of visit. Billed amount will be $ if done after visit and sent as a statement to your home. Insurance Co-payments Policy Insurance co-payments are due at the time of your visit. In some cases we do not know what your co-pay will be until we receive reimbursement back from your insurance company. We will charge a standard co-pay of $35.00 per visit until we determine your co-pay and coverage. At that time we will refund any overpayments back to you or present you with the amount you may owe the Myofascial Treatment Center due to a short fall by your insurance. Because of administrative costs and overhead all insurance reimbursements must meet our cost per visit. If you need clarification on this policy please ask us and we will be happy to explain in greater detail. Signed Date Page 6 of 6 pages
PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:
PRINT CLEARLY NEW PATIENT FORM Name: (first) (last) (m.i) Address: City: State: Zip: Email: Sex: Male Female Student Yes No Home Ph: Cell Ph: Work Ph: Fax: Age: Of Birth: Statement Preference: E-mail Fax
4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB):
Chiropractic Case History / Patient Information
Chiropractic Case History / Patient Information Date: Name: Social Security #: Home Phone:( ) Address: City: State: Zip: E mail address: Cell Phone:( ) Age: Birth Date: / / Marital Status: M S W D Occupation:
CHIROPRACTIC REGISTRATION AND HEALTH HISTORY FORM
CHIROPRACTIC REGISTRATION AND HEALTH HISTORY FORM PATIENT INFORMATION Patient Name: Date: Social security #: Address: E-mail:_ Birthdate: ( ) Married ( ) Single ( ) Divorced ( ) Widowed ( ) Minor ( ) Partnered
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
NEW PATIENT INFORMATION FORM
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PATIENT QUESTIONNAIRE Please fill out this form COMPLETELY using your LEGAL name. Do not leave any blanks. FAMILY PHYSICIAN (First Name, Last Name) PATIENT INFORMATION DATE TO SEE DOCTOR (Name) / / PATIENT
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CHIROPRACTIC PATIENT REGISTRATION AND HISTORY
CHIROPRACTIC PATIENT REGISTRATION AND HISTORY Today s Date: / / Date Symptoms began: / / Is your condition due to an accident? Yes No Type: Auto Work Home Other Name : Address: Last First Middle Street
Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:
Patient Information Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name: Date of Birth: / / Age: SSN: - - Address: City: County: State: Zip: Email
Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB):
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ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE
WELCOME to our office! Please allow our staff to make a photocopy of your insurance card(s) (if applicable). Please Print Clearly PERSONAL INFORMATION: Patient Name: Preferred Name: Address: City/State/Zip:
Patient Information. Insurance Information Who is responsible for this account? Relationship to Patient. Insurance Co: Member ID:
Patient Information Today s Date: Birth Date: SS#: First Name: M. I.: Last Name: Address: City: State: Zip: Sex: M F Age: Email: Cell: ( ) Home: ( ) Emergency Contact: Relationship: Cell: ( ) Home: ( )
Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.
Please arrive to your initial appointment at least 15 minutes early. For all following appointments, please arrive 5 minutes prior to you scheduled appointment time. To avoid waiting unnecessarily remember
New Patient Intake Paperwork
New Patient Intake Paperwork NAME: Last First Middle DATE OF BIRTH: SEX: M / F ADDRESS: Street City State Zip PHONE: MOBILE: EMAIL ADDRESS: EMPLOYER NAME: PHONE: EMPLOYER ADDRESS: EMERGENCY CONTACT: PHONE:
PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber
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If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
AMELIA A. PARÉ, M.D. PATIENT REGISTRATION Date of visit: PATIENT INFORMATION (PLEASE PRINT) Name: Date of Birth: Age: Male Female Race Social Security #: Marital Status: Single Married Divorced Widowed
Patient Registration & Health History
Patient Registration & Health History Today s Date: / / How did you hear about us? Legal Name: How do you prefer to be addressed? Address: City: State: Zip: Date of Birth / / Age: Gender: M / F Marital
Patient Information TO BE COMPLETED BY PARENT/GUARDIAN ACCIDENT INFORMATION. Date SSN/HIC/Patient ID # Patient Name
1 Date SSN/HIC/Patient ID # Patient Name Address PATIENT INFORMATION Best time/place to contact you? E-mail Sex M F Age Date of Birth Married Widowed Single Separated Divorced Minor Patient Employer/School
Patient Registration. D. INSURANCE (if applicable)
Patient Registration A. PATIENT Account #: Address: City: State Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone DOB: SSN #: Gender: Male Female E-MAIL: Check here to receive Electronic
Patient Information Page 1 of 2 *We cannot process your insurance claims without the required fields filled out.
Patient Information Page 1 of 2 *We cannot process your insurance claims without the required fields filled out. Patient s Name*: Today s Date: Street address*: SSN*: City and State*: Zip Code*: Gender:
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Patient Demographic Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Primary Phone: Secondary Phone: D.O.B: Social Security: Driver s License Number: May we leave a message?
Worker s Compensation Intake Form
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MassageWorks Patient Information
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Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
Please list all current medications and supplements that you are taking:
PATIENT HEALTH AND MEDICAL HISTORY Today s Date: Chief Complaint for Today s Visit: Was this injury gradual or sudden onset? Date of sudden onset: Please explain: Do you have a history of present symptoms?
Acknowledgement of Receipt of Notice of Privacy Practices
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FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS NAME: LAST FIRST MIDDLE ADDRESS: STREET APT# CITY STATE ZIP HOME # ( ) WORK# ( ) CELL# ( ) E-MAIL: PREFERENCE: HOME: AGE: DATE OF BIRTH: SS NO.: MALE
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
Are you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure
Patient s Full Name: of Birth: Age: Address: City: State: Zip: Patient Social Security #: Gender: Height: Weight: Cell Phone: Other Phone: E-Mail: Preferred appointment reminder: ( )Text: Cell Phone Provider:
Patient Registration Form
PATIENT INFORMATION Patient Name: of Birth: Age: Marital Status: Married Single Home Phone: Email: Address: Cell: SS#: Divorced Patient Registration Form Account Number: Gender: Widowed Separated Unknown
HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information
Patient Information Name birth date Address (street) apt. # (town, state, zip) Telephone: home cell phone Guardian (if a minor) work e-mail relationship Address (if different) telephone Employer Occupation
MR #: Patient Name: Page: 1 of 4 MAX MOTION PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?
MR #: Patient Name: Page: 1 of 4 MA MOTION PHYSICAL THERAPY PATIENT DATA SHEET First: MI: Last: Date of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages
ACKNOWLEDGEMENT OF DIRECT ACCESS SERVICES
ACKNOWLEDGEMENT OF DIRECT ACCESS SERVICES I,, acknowledge that I am seeking treatment at STAR Physical Therapy, Limited Partnership without a prescription for physical therapy. Please elect one of the
W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By
W E L C O M E PATIENT INFORMATION Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By Date of Birth Social Security # - - Gender: Male Female Marital Status (please circle):
Welcome to our office!
2007 Rainbow Drive Gadsden, AL 35901 Ph: 256-543-0009 Fax: 256-549-1221 Patient Information Page 1of 2 Welcome to our office! Dr. Shan Tian, D. C. Patient Information Please complete all questions. Today
Multi-Specialty Musculoskeletal Pain Relief Center
Name Social Security # Age Birthdate Date Home Tel Address City State Zip Work Tel Cell Number Email Address Marital Status: M S W D # Children Spouse s Name Your Occupation Emergency Contact Name and
EMERGENCY CONTACT INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION
Physician Name: David R. Lionberger, M.D. PATIENT DEMOGRAPHIC INFORMATION SHEET Last Name First Name Middle Social Security No. Date of Birth Age Male or Female (Please circle one) Marital Status: M S
*Married *Widowed *Single *Minor *Separated *Divorced *Partnered for years
Name Last Name First Name M.I. Address City State Zip E-mail Birthdate Age Sex *M *F Occupation Employer/School Employer/School Address Employer/School Phone ( ) *Married *Widowed *Single *Minor *Separated
Name: Date: DOB: / / Age: Nickname (if applicable): Height: Weight: Hand Dominance: R / L
Medical History Name: Date: DOB: / / Age: Nickname (if applicable): Height: Weight: Hand Dominance: R / L Allergies (medications and/or metals): NKDA / PCN / Sulfa / Latex Occupation (if retired, what
Orthopedic Intake. Patient Name: Date of Birth: Age: Sex: Male or Female. What are we seeing you for? Pneumonia vaccine?
Orthopedic Intake Date: Patient Name: Date of Birth: Age: Sex: Male or Female What are we seeing you for? Have you had Flu vaccine? q Yes q No Date Pneumonia vaccine? q Yes q No Date List of Past Surgeries:
chiropractic Bringing Out The Best In You!
chiropractic Bringing Out The Best In You! New Patient Welcome To Our Office SHAWN P. NEVILLE, DC Kennedy Chiropractic 4140 Crain Highway Waldorf MD 20603 301.645.7770 drneville.com drshawn@drneville.com
To all of our new patients
ATLAS FAMILY Thank you for choosing Atlas Family Chiropractic. We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your
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Patient Information, Fill Out Completely PATIENT INTAKE FORM Patient s SS# - - DOB: / / Age: Gender: M / F Marital Status: M S D W Other First Name Middle Last Name Nickname, if any Street Address City
Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male
Patient Information Patient Name: Last First Middle Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: of Birth: / / Social Security #: - - Marital Status:
Today s Date: Name: Birthdate: / / SS#: Home #: Work #: Cell #: Best Time to Contact You:
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