Cell Phone Texting is OK Only call if urgent
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- Irma Johnson
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1 WELCOME! Name (Circle title: Dr., Mr., Mrs., Ms., Miss) of Birth Age Social Security Number Single Married Divorced Separated Widowed Sex Male Female Please check the best number(s) to reach you: Home Phone Work Phone In case of emergency, please contact: Name: Phone numbers: Home/Work: Only call if urgent Only call if urgent Cell Phone Texting is OK Only call if urgent Relationship: Cell: Occupation Employer Name/Company Phone Spouse s Name (if different) of Birth Age Social Security Number Spouse s Occupation Employer Name/Company Names and Ages of your children: Phone What prompted you to choose us: Insurance network Advertisement/ Promotion Personal referral Driving/walking by Internet search/reviews Other Reason for your visit or area of concern: When did your symptoms begin (day/date)? Is this condition getting worse? Yes No Unsure & cause of most recent aggravation? How did it happen, what were you doing? Please put an X on the line below indicating your pain at its worst: No Pain Please put an X on the line below indicating your pain at this time: No Pain Severe Pain Severe Pain
2 Use the bolded letters below on the body diagram to indicate where you are experiencing those symptoms. Type of pain: Sharp Shooting (O) Throbbing Aching Burning Cramping Stiffness (F) Soreness(R) Tingling (G) Swelling/Pressure Numb (no feeling) Dull How often do you these symptoms? Night time 0-25% of awake time 51-75% of awake time 26-50% of awake time % of awake time Activities the condition interferes with: Work Sleep Daily Routine Recreation What makes the condition better? R L R L R What makes your condition worse? (circle) Sitting Standing Lying down Bending Lifting Twisting Changing positions (other) L Women only: Are you pregnant? Yes No Unsure/Possibly of last: Physical Exam: Imaging (xray, MRI, CT): Visit to a Chiropractor: (Who? ) Please list your Primary Care Physician, as well as any other physicians seen for this condition: PCP: What treatments did you receive? Other: Results of prior treatments? Previous injuries, traumas, surgeries, hospitalizations (include description and dates): Current medications (include name, dosage, and reason for taking), and known Allergies: Vitamins, supplements: Work Activity: Sitting Standing Bending Walking Lifting Exercise Level: None Light Moderate Heavy/Intense Habits: Smoking Packs/day Years smoking Alcohol consumption Drinks/week Coffee / caffeine drinks Cups or drinks per day Average Stress Level: Low Moderate High Due to:
3 Health History Name AIDS/HIV Severe/Constant Chills Severe Fatigue Loss of sleep Noticeable weight loss Noticeable weight gain Depression Cancer Chemical or substance dependency/abuse Diabetes Hernia Psychiatric care Stroke Night sweats Thyroid problems Ringing in the ears Sinus trouble Arthritis Fractures Herniated disc Osteoporosis Pinched nerve Foot trouble Low back pain Neck stiffness/pain Shoulder pain Pain/numbness in joints/arms/legs Swollen joints Muscle aches/pains Postural difficulties Sciatica Scoliosis/curvature Bedwetting Blood in urine Frequent urination Painful urination Difficulty starting/ stopping flow Getting up at night to urinate (>3x/night) Inability to control bladder Kidney infection/ stones Sexual difficulties Heart disease High cholesterol Pacemaker High blood pressure Poor circulation Irregular heart beat Varicose veins Asthma Bronchitis Emphysema Pneumonia Eating disorder Liver disease Ulcers Acid reflux/ GERD Belching/gas Constipation Diarrhea Poor digestion Poor appetite Excessive hunger Excessive thirst Vomiting Pain over stomach Black/bloody stool Gall bladder problem Bruising easily Skin cancer Headaches Numbness/tingling Tremors Weakness Dizziness Fainting Convulsions/Epilepsy/ Seizures Men Prostate problem Testicular swelling/ pain Women Painful periods Excessive flow Irregular cycles Hot flashes last period began / / Family History Are there family members that we can help? List which of your relatives the following conditions. Choose from the following: mother, father, brother, sister, grandmother, grandfather, son or daughter. Back pain Neck pain Headaches Diabetes Heart disease High blood pressure High cholesterol Cancer Muscle/bone/nerve disease Other (specify condition)
4 Quality Care Chiropractic Clinic, Ltd S. Eola Road, Suite G Aurora, IL (630) Payment policy (Office Copy) (Patient copy available upon request) Your treatment plan and any therapies used are based on medical necessity, not on your insurance coverage or your ability to pay. If you are concerned about Quality Care Chiropractic Clinic s fees for any therapies, please notify the doctor or office manager immediately. As a patient, you do the right to refuse any of the recommended therapies for your own personal reasons. INSURANCE Payment will be due by you at the time of service for any non-covered services, deductibles, or co-pays. If you a deductible that has not been met, we will collect the full amount of fees for services provided on each visit, up to your deductible amount. Any fees collected exceeding the amount you are responsible for will be applied to future visits, credited to your account, or refunded upon request when there are no outstanding balances on your account. Your insurance policy is a contract between you and your insurance company. Quality Care Chiropractic Clinic has no authority over your benefits or coverage. While Quality Care Chiropractic Clinic does its best to work with your insurance company, the benefits quoted to us by your insurance company are not a guarantee of payment, and you are ultimately responsible for all fees for services provided. If your insurance denies payment for services you received, you will be required to pay for those services in full. CASH or SELF-PAY If your insurance cannot be verified at the time of service, you do not insurance or your insurance policy does not cover our services, then all fees must be paid in full, with applicable time-of-service discount. If you pay for all services rendered on the day that they are performed (time-of-service), then you are entitled to a reduction in the fees. If you pay at a later date, the reduced rate does not apply. You are responsible for paying your entire account balance, according to the terms listed above, regardless of perceived value, effectiveness of therapy, or expected outcomes. If you are the guantor, parent or guardian of a minor being treated by Quality Care Chiropractic Clinic or its physicians, you hereby acknowledge that you are solely responsible for the payment of all bills incurred in the treatment of your minor child. If financial hardship can be verified, we can establish a payment plan. When you receive a statement for payment due, the due date will be printed on the statement. Quality Care Chiropractic Clinic must receive payment by the due date. If no payment is received after two notices, your account may be turned over to our collection agency, and any unpaid balances can be reported to the credit bureau which would be reflected on your credit report as a delinquent account. If you any amount that is Past Due on your account, any new balances will also be considered due immediately with no grace period for payment. In the event Quality Care Chiropractic Clinic undertakes any type of legal action to collect unpaid balances, you understand that you are obligated to pay any and all court costs and reasonable attorney fees incurred by Quality Care Chiropractic Clinic. The contact information you provided on the intake form will be used to notify you. The address you provide is where Quality Care Chiropractic Clinic will send all correspondence. The phone numbers provided will be where Quality Care Chiropractic Clinic will call to notify you. If this information changes you are responsible for notifying Quality Care Chiropractic Clinic immediately to prevent any miscommunications. I read and understand all of the information contained in this payment policy. All of my questions been answered to my satisfaction. To the best of my knowledge, the information I provided is true and accurate. I understand that I am ultimately responsible for paying for any services that I receive from Quality Care Chiropractic Clinic and its employees. Signature: :
5 Quality Care Chiropractic Clinic, Ltd S. Eola Road, Suite G Aurora, IL (630) Patient Acknowledgement and Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent for Use of Health Information Name Print Patient s Name The undersigned does hereby acknowledge that he or she has received a copy of this office s Notice of Privacy Practices Pursuant To HIPAA and has been advised that a full copy of this office s HIPAA Compliance Manual is available upon request. The undersign does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State law and Federal Law. d this day of, 20 By Patient s Signature If patient is a minor or under a guardianship order as defined by State law: By Signature of Parent/Guardian (circle one)
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in Patient Information Thank you for choosing our practice for your chiropractic needs. Please
York Chiropractic Clinic Registration and History
York Chiropractic Clinic Registration and History PATIENT INFORMATION Date _ First Name Last Name Address City State Zip Code Sex Male Female Date of Birth: Home Phone ( ) Cell Phone ( ) Best place to
PATIENT REGISTRATION FORM Account #:
PATIENT REGISTRATION FORM Account #: All forms must be completed and signed prior to treatment. GENERAL INFORMATION Patient Name: First Middle Last Address: Home Phone No: Work Phone No: Cell Phone No:
Patient Name: Address: Date of Birth: Age: Marital Status: S M D W. Mailing Address: Home Phone #: Cell Phone #:
Patient Information Patient Name: E-Mail Address: Sex: M F Date of Birth: Age: Marital Status: S M D W Mailing Address: Home Phone #: Employer/School: Cell Phone #: Occupation: How were you referred to
entral Chiropractic Center
Patient Information Date: Name Sex M F Birthdate last middle initial first Address Marital Status Single Married Widowed Separated Divorced Social Security # Occupation Primary Phone Secondary Phone Emergency
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 Information. Insurance Information
Date Name (LAST NAME) (FIRST NAME) (MIDDLE INITIAL) Address City State Zip Phone (HOME) Patient Information (CELL) Email Birthdate Age Sex: M F Social Security # Occupation Employer Do you have health
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP 34 Long Pond Road Plymouth, MA 02360 (508) 747-1434 New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic
Acknowledgment of Receipt of Notice
Acknowledgment of Receipt of Notice patient acknowledgment I acknowledge receipt of a copy of Maximum Mobility s Notice of Privacy Practices with an effective of January 1, 2012. printed name of patient
*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
3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
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
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Email Date of
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Patient Name: DOB: Address: ADDRESS CITY, STATE, ZIP SSN: Mailing Address: ADDRESS CITY, STATE, ZIP Same as above Home phone: Cell phone: Work phone: Marital Status: Single /
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
Olathe Chiropractic S. Mur-Len Road - Olathe, KS Dr. Jeremy Landry Dr. Joseph Anderson New Patient Intake Form
Olathe Chiropractic 15930 S. Mur-Len Road - Olathe, KS 66062-8301 Dr. Jeremy Landry Dr. Joseph Anderson New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial
How did you learn about our office? Patient s Last Name: First: MI: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )
Date: / / How did you learn about our office? Patient s Last Name: First: MI: Sex: Male Female Date of Birth: / / Age: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Social
ADDRESS CITY / STATE / ZIP CODE RACE/ETHNICITY WORK PHONE # ( ) ADDRESS MAY WE CONTACT YOU BY YES NO
PATIENT REGISTRATION Patient Information (please print) PATIENT NAME (last, first, middle) SOCIAL SECURITY # SEX: M F DATE OF BIRTH AGE ADDRESS CITY / STATE / ZIP CODE RACE/ETHNICITY HOME PHONE # CELL
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:
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
2345 Court Drive Gastonia, NC Phone: Fax:
Patient Name: Address: Street City State Zip SSN: Home #: Birth Age: Sex: Male Female Email Address: Marital Status: Single Married Divorced For X-ray purposes, are you pregnant? Yes No Patient s Employer:
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(
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
Thank you again for choosing Haymarket Chiropractic. We hope to exceed your expectations.
Dear New Patient, The Staff at Haymarket Chiropractic & Rehabilitation (HCR) and I are delighted that you have chosen our facility for your therapy. Our goal is to provide you with a premium level of care
Welcome to BetterBody Solutions
Welcome to BetterBody Solutions Please fill out our history forms completely and accurately to the best of your ability so that we can quickly get you on the road to health. We appreciate you choosing
Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?
Welcome to Rizzo Chiropractic Holistic Health and Wellness Center Check the following services you are interested in: Chiropractic Physical Rehabilitation Nutritional Analysis (Hair, Blood & Urine) Detox
entral Chiropractic Center
Patient Information Date: Name Sex M F Birthdate last middle initial first Address street/p.o. box city state zip Marital Status Single Married Widowed Separated Divorced Social Security # Occupation Primary
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
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
Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
INSTRUCTIONS. Once you complete the forms, save the file to your desktop for your records, then attach in an to:
INSTRUCTIONS For your convenience you can fill out the following forms on your computer if you have Adobe Acrobat Reader installed. Fields are highlighted in blue. Use the tab key to move from field to
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
Thank you again for choosing CrossRoads for your care. We hope to exceed your expectations.
BELIEVE! COMMIT! ACHIEVE Dear New Patient, The staff at CrossRoads Physical Therapy and I are delighted that you have chosen our facility for your therapy. Our goal is to provide you with a premium level
PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber
PATIENT INFORMATION : Please present insurance cards to receptionist First Name: Last Name: Date of Birth: - - Sex: Male Female Address: City: Cell Phone #: ( ) - M.I.: APT: State: Zip Code: Home #: (
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
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 #:
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle
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:
CHIROPRACTIC REGISTRATION AND HISTORY
CHIROPRACTIC REGISTRATION AND HISTORY 229 N Andover Rd Suite 200Andover, KS 67002 (316)-733-0715 PATIENT INFORMATION Date / / SS # - - E-Mail Patient Name Last Name First Name Middle Initial Address City
PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Last Name First Name Address City, State, Zip Email Address Home Phone Work Phone Cell Phone SS# Date of Birth Age Sex ( ) Male ( ) Female Marital Status (check one):
University Spine Institute Inc
University Spine Institute Inc TREATMENT ADVISEMENT: The physicians of University Spine Institute are specialists in pain management. The examinations and treatments that you will receive here cannot be
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY Dear Patient, Thank you for choosing Michael K. Block, DPM, LLC for your podiatric needs. We value our relationship with you and would like to tell you
Patient s Printed Name:
OSI PHYSICAL THERAPY AUTHORIZATION TO TREAT: I voluntarily consent to therapy care encompassing evaluation and treatment procedures. I acknowledge that no guarantees have been made to me about the results
Chong S Kim, MD ENT and Facial Plastic Surgeon
Chong S Kim, MD ENT and Facial Plastic Surgeon 100 Commons Way, Suite 701 300 Perrine Rd., Suite 301 Holmdel, NJ 07733 Old Bridge, N.J 08857 Phone: 732-796-0182 Phone: 732-727-1355 Fax: 732-796-0186 Fax:
Was this the first time you heard of IPT? Therapist: PATIENT INFORMATION Home Phone:
1144 HWY 59 SUITE 3 MANDEVILLE, LA 70448 PH (985) 778-2540 FAX (985) 778-2542 Appt : Who referred you to IPT? Time: Was this the first time you heard of IPT? Therapist: Y N If no, where? Initials & of
CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.
PATIENT INFORMATION First Name: Middle Initial: Last Name: Mailing Address: Street Address: City: County: State: Zip: Phone #: Work: Ext: Would you like us to text you? Yes No Cell #: Driver s License
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:
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: ( )
Patient Information. Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other
Patient Information Date: Name: Birth Date: Age: Marital: M S W D Address: City: State: Zip: E-mail address: Phone: Occupation: Employer: Spouse: Occupation: Employer: How many children? Names and ages
Patient Register. Name: Social Security # Birth date: Occupation: Employer:
Patient Register Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: Home Phone: Male: Female: Social Security # Birth date: Occupation: Employer: Email:
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:
Whom or What May We Thank For Your Referral? Employment Information: Emergency Contact:
Date: Patient Demographics: Last Name: First Name: MI: DOB: / / Age: Gender: M / F SS#: - - Marital Status: #of Children: Employment Status: Address: PO Box # City: State: Zip: Home Phone: Cell Phone:
Family Medicine Center of the Bitterroot, P.C.
PATIENT REGISTRATION / FINANCIAL AGREEMENT Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges
WEST MICHIGAN CHROPRACTIC CENTER, P.L.C.
WEST MICHIGAN CHROPRACTIC CENTER, P.L.C. By signing below, I acknowledge that I have received a copy of the Notice of Privacy for Protected Health Information and Consent For Use or Disclosure of Health
Chiropractic Case History
Chiropractic Case History Name Sex M F Date Address City State Zip H. Phone( ) W. Phone Date of Birth Age Cell Phone ( ) Email Address: Referred by Social Security # Occupation Employer Have you ever received
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
Welcome to MARTIN CHIROPRACTIC
Welcome to MARTIN CHIROPRACTIC 225 E. Buena Vista Street, Barstow, CA 92311 (760)-256-2171 www.drscottmartin.com Name: Date of Birth Age Last First Middle Initial Address: Social Security # City State
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
Chief Complaint Form: Patient Name: Date: First MI Last Preferred Name Age: DOB: Occupation: Employer: Send Note? Referring Physician: Town: Y N Primary Care Physician: Town: Y N Coach/ Trainer/ Team Doctor:
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
Gulf Coast Sport & Spine, LLC
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. First Name Middle Initial Last Name Address City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Email Date of Birth /
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,
1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO 80012 303.923.3369 www.metrofoot.org 303.923.3882(fax) Please print and complete all parts. Date PATIENT INFORMATION
Patient Information. Name Date. Address City Zip. Age Date of Birth / / Marital Status M S D W. Social Security # Driver s License #
Patient Information Name Date Address City Zip Age Date of Birth / / Marital Status M S D W # of Children Social Security # Driver s License # May Ashby Chiropractic Clinic communicate with you by: Telephone
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:
NEW PATIENT INFORMATION
12101 W. Parmer Lane Ste. 200 Cedar Park, Texas 78613 Phone: 512.363.5178 Fax: 512.339.2664 Welcome!!! Please allow our staff to photocopy your driver s license and insurance or Medicare card (if applicable).
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / /
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y. 14814 DATE: / / PATIENT INFORMATION FORM (PLEASE PRINT) PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX:
Adair Health Care Certified Applied Kinesiologist Tim Adair DC 833 A. Wren Rd Goodlettsville,Tn phone Fax
833 A. Wren Rd Goodlettsville,Tn 37072 phone- 615-239-8676 Fax-615-239-8325 DOCTOR-PATIENT RELATIONSHIP IN CHIROPRACTIC INFORMED CONSENT CHIROPRACTIC Chiropractic health care seeks to restore health through
Patient Registration Form
Patient Registration Form Date: Name: Maiden Name: (First) (MI) (Last) SSN: Birth Date: Age: Marital Status: Sex: M or F Race: Ethnicity: Language: Mailing Address: City: State: Zip: Physical Address:
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
Cardholder Name: Patient Name: Relation to Patient: Sex: Cardholder s DOB: Co-pay: Member ID#: Group #:
2121 Whitesburg Drive, Suite C Huntsville, AL 35801 Name: DOB: Sex: Age: Address: City: State: Zip Code: Primary Phone: Secondary Phone: SSN: Preferred Language: Race: Employer: Occupation: Work Phone:
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX Phone: Fax: Address: City: ST: ZIP:
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX 75082 972-649-5937 Fax: 972-807-0385 Patients General Information Last Name: First Name: Patient s SSN: of Birth MM/DD/YYYY: / / Age: Sex: M/F
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 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:
Dr. Adam J. Farber PATIENT DEMOGRAPHIC FORM (THIS FORM IS TO BE UPDATED YEARLY OR WITH ANY INFORMATION CHANGES)
Dr. Adam J. Farber Patient Information: PATIENT DEMOGRAPHIC FORM (THIS FORM IS TO BE UPDATED YEARLY OR WITH ANY INFORMATION CHANGES) Name: (First) (Middle) (Last) Name you prefer to go by: Height: Weight:
PATIENT RECORD Please fill out completely. Thank you. Referring Physician. Last Name Legal First Name MI
PATIENT RECORD Please fill out completely. Thank you Date Referring Physician Last Name Legal First Name MI Mailing Address City ST. Zip Home Phone CellPhone Sex Birth Date Social Security # Email address:
SCHNEIDER CHIROPRACTIC, LLC
523 North Elm Street-Lincoln, IL 217.732.2140 WELCOME The doctors and staff of Schneider Chiropractic welcome you and want to provide you with the best possible care. We will conduct a thorough history
AUTO ACCIDENT INTAKE FORM
AUTO ACCIDENT INTAKE FORM Last First Middle Birthdate / / Address City State Zip Phone Number (cell) (home) Today s Date / / Email Occupation Employer Spouse s Name Spouse s Phone Number Who may we thank
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
Corona-Temecula Orthopaedic Associates P H Y S I C A L T H E R A P Y A N D W E L L N E S S C E N T E R
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
Patient Information Last Name First Name Middle Initial
Patient Information Last Name First Name Middle Initial Street Address Apt# City State Zip Code Social Security # Home Phone Cell Phone Email D.O.B Sex(M/F) Occupation Relation to Insured Self Spouse Child
Bartram Family Chiropractic
Bartram Family Chiropractic Today s Date: / / Check in box indicates no changes below Patient Name: _ Male Female Date of Birth: / / Age: Social Security Number: - - Marital Status: Single Married Divorced
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Today's / / PATIENT INFORMATION Patient Name Last First Middle Mr Mrs Marital Status (circle) Miss Ms Single/ Married / Divorced /Sep/ Widow Is this your legal name? If not, what
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
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Date of Birth Social Security Number - - First Name MI Last Name Address City State ZIP Phone (H) (W) (Cell) (Please circle the preferred contact number) Email Address Occupation Full Time/Part Time Employer
Date. D Light D Moderate D Strenuous
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