SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
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- Jeffrey Bradley
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1 Patient Name: Date of Birth: / / Last First Day Month Year Address: City: Home Tel: Other Tel: Postal Code: * Family Physician: Do you have a Doctors referral? How did you hear about us? If so, from what Doctor? *By adding your , we will send you appointment reminders, your home exercises and occasional newsletters your will never be shared with any other organization OFFICE USE ONLY:
2 Health Questionnaire 1. Date of accident / injury? 2. Are you taking any medications? If yes, please specify 3. Did you have any X-rays taken for this problem? If yes, which areas Do you know the results? 4. Do you have any of the following: (please check appropriate items) High or low blood pressure Thyroid problem Lung problem Cardiac problems Kidney problem Pacemaker Arthritis Osteoporosis Recent, unexplained weight loss Cancer (presently or in the past) Diabetes Dizziness Headaches Abdominal problem Depression Anxiety Allergies Skin problem 5. Have you ever broken a bone? If yes, where 6. Do you have any metal fixations, screws or plates in your body? 7. In the past have you had any of the following: (please check and explain) Major surgeries Car accidents Work or sport related injuries 8. Do you smoke? 9. Are you currently working? If yes, full-time or part-time 10. For the ladies only --- Are you pregnant? If yes, how many months? I hereby confirm that the above information, to be the best of my knowledge, is correct. Signature Date
3 TEL: (905) FAX: (905) Consent to Treatment at Sheddon Physiotherapy and Sports Clinic 1. I hereby authorize Sheddon Physiotherapy to obtain or release any required information pertaining to my health and rehabilitation. Information may be obtained or released to: Family Physician Insurance Company (if MVA) Employer (if WSIB) 2. I consent to being assessed by a Sheddon Therapist which may include treatment. I will be informed of the treatment Pros and Cons by the Sheddon Therapist and am also aware of my right to withdraw my consent, verbally, to treatment, at any time. Date Print patient / guardian name Print name of witness Signature of patient/guardian Signature of witness 3. I have read / understood the Clinic s 24 hour cancelation policy. Initial: 4. If any third party payer (insurance company) refuses to pay for my claim, I accept responsibility for any unpaid balance on my account. Initial: Informed Consent to Spinal Manipulative Therapy Doctors of Chiropractic and Physiotherapists who use manual therapy techniques such as spinal adjustments (manipulations) are required to advise patients that there are some risks associated with such treatment. In particular, you should note: While rare, some patients have experienced muscle strain, ligamentous sprain and rib fracture following spinal adjustments (manipulation). There have been reported cases of injury to the vertebral artery (blood vessel located in the neck) following adjustment (manipulation) to the neck (cervical spine). Vertebral artery injuries have been known to cause stroke, sometimes with serious neurological impairment. The possibility of such injuries resulting from neck spinal adjustment (manipulation) is extremely rare and occurs almost entirely in the top-most region. There have been rare reported cases of disc injuries following neck or low back spinal adjustment (manipulation). However, scientific study has not supported that such injuries are caused or may be caused, by spinal adjustments. Chiropractic and Physiotherapist treatment, including spinal adjustment (manipulation) has been the subject of government reports and multi-disciplinary studies conducted over many years. These reports and studies have demonstrated treatment to be effective for spinal pains, headaches and other similar symptoms. These treatments may contribute to your overall well-being. The risk of injuries or complications from treatment is substantially lower than that associated with the other treatments, medications and procedures given for the same symptoms. I acknowledge, I will discuss, with therapist, the nature and purpose of treatment in general and my treatment in particular as well as the content of the Consent. I consent to the Chiropractic or Physiotherapy treatment offered or recommended to me by my therapist including spinal adjustment (if warranted). I am of legal age to give consent. Signature: Date:
4 Electronic Transmission Authorization and Consent Form Instructions: This form must be filled out when claims are submitted electronically by the provider on the patient s behalf. Please retain this form in the patient s file for verification purposes for two years following closure of the patient file. Provider: Sheddon Physiotherapy and Sports Clinic Address: 1300 Cornwall Rd, Suite 103 City/Province: Oakville/Ontario Postal Code: L6J 7W5 Phone Number: Insured Member: Patient: Address: City/Province: Postal Code: Phone Number: Plan Number: Certificate / ID Number: Consent to Collect and Exchange Personal Information Message to the Plan member, Spouse and/or Dependent regarding Personal Information Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse. Authorization and Consent I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize the insurer and / or plan administrator and their service provider(s) to: - Use my personal information for the above purposes. - Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes - Exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member. - Exchange personal information of the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law. I understand that a photocopy or electronic version of this authorization shall be as valid as the original and may remain in effect for the continued administration of the group of benefits plan.
5 Additional Consent Applicable to Plan Members Only I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose. Signature: Date: Print Name: Benefit Assignment Form I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided. I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider. Signature: Date: Print Name:
SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
INTAKE FORM Patient First Name Patient Last Name Date of Birth: / / DD month YYYY Address: City: Prov: Postal Code: Mobile Tel: Home Tel: Accepts to receive SMS Text message appointment reminders *E-mail:
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
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:
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
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PATIENT REGISTRATION
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Patient Health Information Consent Form
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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):
PATIENT INFORMATION. Name Soc. Sec. # - - Last Name First Name Initial Address. City State Zip code. E mail address Sex M F Age Birth date
PATIENT INFORMATION Name Soc. Sec. # - - Last Name First Name Initial Address City State Zip code E mail address Sex M F Age Birth date Home phone Mobile phone Work phone In case of emergency who should
Personal and Family Health History
Personal and Family Health History Name Date of Service Address Phone: (H) City State Zip (W) E-mail Marital Status S M D W Date of Birth (Age ) Occupation Employer Spouse s Name Spouse s Occupation In
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NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION PLEASE REVIEW IT CAREFULLY FUQUA PHYSICAL
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
Name Relationship Phone #
Patient Name: Preferred Name: Last First Middle Gender: Male Female Other Date of Birth (dd/mm/yyyy): Occupation: Home Address: City: Postal Code: Were you injured at work? Is this an ICBC case? If so,
WELCOME TO OUR OFFICE
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HEALTH QUESTIONNAIRE. Today s Date Date of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No
Name HEALTH QUESTIONNAIRE Today s of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No If yes, type and amount: Alcohol Use: How many drinks do you have per week? Hand Dominance: Left
Patient Registration Form
Patient Registration Form Patient Information Account # : Address: Primary Phone: Please indicate the best number for your appointment reminder calls: Home Cell Text Alternate Phone: Email: May we contact
Patient Information. Welcome. Here s what you can expect on your first visit:
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Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
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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?
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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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Practice Member Health Questionnaire
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Patient Case History
Patient Case History Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Email Address: Preferred Contact: Home Phone Cell Work E-mail Employer & Occupation: Date of Birth:
Medical Information Sheet
Medical Information Sheet Name: Date: Age: Sex: M F Height: Weight: Dominant hand: R L Occupation: Presently working: Y N Reason for being seen today: Date of Onset: Involved side: R L Both Describe any
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New Patient Referral and Insurance Verification Form
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MR #: Patient Name: Page: 1 of 4 MADISON SPINE & PHYSICAL THERAPY PATIENT DATA SHEET
MR #: Patient Name: Page: 1 of 4 MADISON SPINE & 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
CHIROPRACTIC HEALTH QUESTIONNAIRE
CHIROPRACTIC HEALTH QUESTIONNAIRE Name: SS#: Today s Date: / / Address: City: State: Zip: What you prefer to be called: Age: Birthdate: / / Handedness: Height: Weight: Number of Children: Male Female Marital
REASON FOR TODAYS VISIT Is this injury / condition related to your..
DATE: PATIENT INFORMATION Patient Name: First Middle Last Male Female Address: City: State: Zip: Home phone: Cell: Date of Birth: Marital Status: married single other Soc Sec #: Drivers Lic. # Email Address:
MR #: Patient Name: Page: 1 of 4 CAPE COD HAND & UPPER EXTREMITY THERAPY PATIENT DATA SHEET
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Joint Chiropractic Case History/Patient Information
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NEW PATIENT QUESTIONNAIRE
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PATIENT INFORMATION Patient Demographics and Insurance
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Patient Intake Form Patient Information
Patient Intake Form Patient Information Full Name: First MI Last Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Email Address: Home Phone: Work Phone: Cell/Other: I prefer to receive calls
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
Best Time To Call. Referring Physician:
Page: 1/6 EXCEL PHYSICAL THERAPY PATIENT DATA SHEET DO NOT EMAIL The electronic form is provided for your convenience. With respect to responding to this form, please do not send via email. Please populate,
Name: Social Security: Address: City: State: Zip: Birthdate: Age: address: Cell Telephone: ( ) Fax: ( )
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will
Do we have your permission to leave a message on your voic ? Referring Physician: PCP: Occupation: Employer: Primary Insurance: ID#: Group#
Name: D.O.B: / / Title First Last Address: Street City State Zip Cell Phone: Home Phone: Work Phone: Email Please place an X next to your preferred communication method Do we have your permission to leave
Hun Chiropractic 1 Creekview Ct, Suite B Greenville, SC P: F:
1 Creekview Ct, Suite B Greenville, SC 29615 Personal Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: Age: Social
(Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION. If not, what is your legal name? (Former name): Birth date:
Today s date: (Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION Last name: First: MI: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Name: Primary Phone: Secondary Phone Address: City: State: Zip: Social: Age: DOB: Height: Weight: Primary Physician: Referral Source: Email Address: HISTORY Chief Complaint: Where
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Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you.
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you. Name: Social Security: Address: City: State: Zip: Birthdate: Age: E-mail
Prairie Life Chiropractic 1224 S. Main Ave. Sioux Center, IA 51250
Patient Information Name Birth Date Guardian s Name (If applicable) Address City State Zip Home Phone ( ) Cell ( ) Email Sex: Age SS# Race: Ethnicity: Occupation Employer Employer City Employer Phone(
Chirohealth 825 NE. 7 th St Grants pass OR Patient Information. Occupation: Employer s Address: Alternate contact person: name
825 NE. 7 th St Grants pass OR 97526 Dr. David Ray D.C. FNP Dr. Todd Harris D.C. Eve Ledesma PT Patient Information Name: Date: Address: Birth Date: City, State, Zip: Male / female Home Phone: Cell Phone:
PATIENT REGISTRATION FORM
Today s PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First: Mi. Init: DOB: Age: SSN: Gen: M F Marital Status: S M D W Race: African American American Indian Asian Caucasian Hispanic Pacific
Family History: Cancer Diabetes High Blood Pressure Heart Problems/Stroke Rheumatoid Arthritis
INITIAL HEALTH STATUS Sex M/F Patient Name: Birthdate: Age: Address: City: State: Zip: Phone ( ) Email: Occupation: Employer: Work Phone( ) Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber
MR #: Patient Name: Page: 1 of 4 ADVANCED PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?
MR #: Patient Name: Page: 1 of 4 ADVANCED 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 relating
PATIENT INFORMATION PRIMARY INSURANCE INFORMATION
1001 Medical Plaza Dr. The Woodlands, TX 77380 www.woodlandsretina.com Tel: 281-367-9700 Fax: 281-367-9701 PATIENT INFORMATION Patient s Legal Name: Date of Today s Visit: Social Security # Date of Birth:
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MR #: Patient Name: Page: 1 of 4 HAMILTON PHYSICAL THERAPY SERVICES PATIENT DATA SHEET
MR #: Patient Name: Page: 1 of 4 HAMILTON PHYSICAL THERAPY SERVICES PATIENT DATA SHEET First: MI: Last: Date of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages
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:
Integrated Spinal Solutions Patient Information
Integrated Spinal Solutions Patient Information Patient Name: City/State/Zip: Today s Date: Home Telephone: Work Telephone: Birth Date: Age: Cellular Telephone: Height: Weight: Employer s Name: Social
PATIENT INFORMATION ADDRESS STREET CITY STATE ZIP HOME ( ) WORK ( ) EXT. CELL ( ) PERSON RESPONSIBLE FOR ACCOUNT: OCCUPATION: EMPLOYER: CDL#:
PATIENT INFORMATION DATE FIRST NAME LAST NAME ADDRESS STREET CITY STATE ZIP HOME ( ) WORK ( ) EXT. CELL ( ) BIRTH DATE / / AGE SS# - - MARITAL STATUS: S M. D. W PERSON RESPONSIBLE FOR ACCOUNT: OCCUPATION:
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PATIENT INFORMATION. Today's Date: (PLEASE PRINT) Soc. Sec.# - -
PATIENT INFORMATION Today's Date: (PLEASE PRINT) Soc. Sec.# - - Name: First Middle Last Nick Name Sex: M F Birth date: Age: Current Student Grade Level: Full Time / Part time Single / Married (Circle One)
PHYSICAL THERAPY CENTRAL
PHYSICAL THERAPY CENTRAL PATIENT INFORMATION Patient Name: Address: City: State: Zip: Employer: Birthdate: Age: Home Phone: Cell Phone: Work Phone: Preferred Contact Method for Appointment Reminders: Home
HEALTH QUESTIONNAIRE. Today s Date Date of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No
Name HEALTH QUESTIONNAIRE Today s of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No If yes, type and amount: Alcohol Use: How many drinks do you have per week? Hand Dominance: Left
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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 INFORMATION
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City: State: Zip: Home Cell Work Alternate Phone: Address: Home Cell Work Sex: Male Female Marital Status: Single Married Other:
Denton Sanger Aubrey Patient Information Patient Registration Information Name: (First) (MI) (Last) Social Security #: Date of Birth: Address: Phone: City: State: Zip: Home Cell Work Alternate Phone: Email
PS CHIROPRACTIC PATIENT CASE HISTORY
PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security
Personal Insurance Intake Form
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
PATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:
PATIENT INTAKE FORM (Please Print or Type. Once complete, either fax to 949-553-3561, email to Stacie@thephysiofix.com or bring with you during your first session!) Today s date: PATIENT INFORMATION Patient
Spencer Family Chiropractic
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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
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
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
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: ( )
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 History Form
Patient History Form Name: Sex: Male Female Age: Height: ft in Weight lbs 1 Are you currently working? Yes No (last day worked: ) 2 Please give your occupation and physical demands: 3 List your complaints
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Patient Full Name: E-Mail Address: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Emergency Contact Name/number: Occupation: Status: Employed Full Time Student Part Time Student
Patient name: LAST FIRST MIDDLE. Address: Responsible Party SS#: Required If patient a minor and/or full-time student. Employer: Occupation:
PATIENT Information SHEET ACCT # PT Patient name: LAST FIRST MIDDLE Date of Birth: Age: (please circle :) Female Male Address: Responsible Party SS#: Required If patient a minor and/or full-time student
Is a 3 rd party settlement anticipated (lawsuit, auto accident, etc)? Yes No
PATIENT INFORMATION Patient Name Date of Birth Home Address Soc. Sec. No. Home Phone Work Phone Email Cell Phone Physician Date of Surgery Date of injury/flare up Cause Date of next Dr. appt. Referred
Advanced Therapy Solutions
Advanced Therapy Solutions Patient First Name Address City State Zip Social Security # Date of Birth / / Sex: M or F Drivers License # Marital Status: Single, Married, Divorced Email Address: @ Home Phone
PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
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
Patients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
Patient Health Questionnaire
Patient Health Questionnaire Account # Patient Name DOB / / 1. Describe your symptoms/complaints or limitations: 2. Please describe how your problem began: 3. When did your symptoms begin/specific date
Worker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
PATIENT REGISTRATION FORM
Today s Date: PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First: Mi. Init: DOB: Age: SSN: Gen: M F Marital Status: S M D W Race: African American American Indian Asian Caucasian Hispanic Pacific
KRAIG R. PEPPER, D.O. P.A.
Thank you for choosing Dr. Kraig Pepper, D.O. P.A. for your care. The following is required to provide you with the quality medical care. The doctor and staff will review this information and place it
Date. D Light D Moderate D Strenuous
FAMILY CHIROPRACTIC CARE PATIENT HEALTH QUESTIONNAIRE Patient Name What type of regular exercise do you perform? D None Date D Light D Moderate D Strenuous What are your overall health goals? D Weight
New Patient Registration
New Patient Registration Personal Information Last Name: First Name: Middle initial: Street Address: City: State: Zip: Birth date: Age: Sex: M F Social Security Number : Home phone: ( ) Work phone: ( )
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
PATIENT CASE HISTORY
Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM 87505 505-984-0006 www.spchiro.net PATIENT CASE HISTORY Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell
Chiropractic Case History/Patient Information
1 Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E. Chiropractic Case History/Patient Information 100 Ridgeway St., Suite 8 Hot Springs, Arkansas 71901 P 501-463-9477 F 501-463-9478 Date: Patient # Doctor: