For Motor Vehicle Accidents: Passenger name(s):
|
|
|
- Primrose Kelly
- 5 years ago
- Views:
Transcription
1
2 Insurance Coverage Information Page 2 Medical Insurance Insurance Carrier: Phone: Policy Holder Name: Policy Number: Group Number: For Motor Vehicle Accidents: Passenger name(s): Were you: Driver / Passenger / Pedestrian / Other Do you have "Med Pay" or PIP on your Auto Policy: (PLEASE CIRCLE) Yes / No / Not Sure Auto Insurance Carrier Name: Phone: Policy #: Adjuster: Claim Number: Date of Accident: Did you receive emergency medical treatment from a hospital or medical center? (PLEASE CIRCLE) Yes / No If yes please provide the name of the hospital or medical center that you treated at: (PLEASE CIRCLE) Were you transported from the accident by ambulance? Yes / No (PLEASE CIRCLE) Have you retained an attorney? Yes / No Attorney s Name: Please Describe Accident:
3 Workers Compensation Page 3 Date of injury Approx. time of injury am pm Company/Business name where injury occurred Company/Business address where injury occurred City State Phone # Date you last worked at your place of injury To the best of your knowledge please describe the accident as it occurred: Was accident reported to your employer? YES NO Name of person reported to: Their job title/position Phone # (I.e. Supervisor, Manager, co-worker, friend) YES NO Were you treated for this injury? If YES, doctor s name Type of treatment you received: How many times were you treated by the above mentioned doctor? Are you: Improved Unchanged Getting worse YES NO Did you ever have any previous accidents or injuries? If YES, list date, type of injury and doctor who treated you or hospital: YES NO YES NO Are you currently out of work? Have you returned to work? If YES, date in which you returned: Name of compensation carrier: Address of carrier: Claim# AUTHORIZATION OF PAYMENT I hereby authorize direct payment to 1st Care benefits due me for his services. I also authorize release of information to all my insurance carriers. I understand I am financially obligated and responsible for all charges for services rendered to me that are not covered by my insurance. Print name Signature Date
4 Present Complaints (please circle the appropriate ones) Page 4 Headache Feet / Hands cold Head seems heavy Pins and needles in arms Mental dullness Depression Confusion Right / Left Loss of memory Pins and needles in arms Constipation Pins and needles in hands Dizzy Rib pain Unbalanced Right / Left Neck Pain Neck stiffness Chest pain Pins and needles in legs Fainting Shortness of breath Ears ringing/buzzing Right / Left Upper back pain Upper back stiffness Midback pain Midback stiffness Lower back pain Lower back stiffness Blurred vision Double vision Neck restriction Eye strain / pain Loss of taste Loss of smell Nervousness Fear Irritability Tension (PLEASE CIRCLE) Difficulty in: Standing, Sitting, Bending, Walking (PLEASE CIRCLE) Pain radiation to the: Right arm, Left arm, Right leg, and Left leg (PLEASE CIRCLE) Cannot lift: Light, Moderate, and Heavy, Repetitively (PLEASE CIRCLE) Pain radiating to: Neck, Base of skull, Ribs, Shoulders, Arms (PLEASE CIRCLE) Pain in the: Foot, Ankle, Knee, Hip, Heel spurs OTHER: Since the time this (these) complaint(s) began, what, if anything, have you tried that did not work? (PLEASE CIRCLE) Have you missed work as a result of this problem? Yes / No if you answered yes What date did you stop working? List any doctors or therapists that you have seen for this complaint: 1. Specialty 2. Specialty 3. Specialty Relevant medical history: (Please circle the conditions you have or had previously) Arthritis Epilepsy Muscular Dystrophy Asthma Fibromyalgia Neck pain or spasms Anemia Hand or wrist pain Neuritis Back pain or spasm Headaches Numbness Cancer Heart problems Polio Concussion Hepatitis Rheumatic Fever Convulsion High blood pressure Sinus trouble Diabetes HIV Sciatica Digestion problems Measles TB Dizziness Multiple sclerosis Venereal disease
5 Present Complaints continued Page 5 List any operations, illnesses, or accidents that you've had, approximate dates, and treating doctor: 1. Date: Dr: 2. Date: Dr: 3. Date: Dr: 4. Date: Dr: Are you taking any medications? Please list: Are you allergic to any medication? Please list: (PLEASE CIRCLE) Are you pregnant? Yes / No Due date: (PLEASE CIRCLE) Do you smoke? Yes / No Amount per day: (PLEASE CIRCLE) Do you drink? Yes / No What type of drinker are you? Light Medium Heavy (PLEASE CIRCLE) How often do you Exercise: Never Sometimes Frequently Regularly I attest that the above information is true and correct to the best of my knowledge. I understand that because of specialized procedures, testing, and reporting, 1 st Care does not participate with managed care health insurance plans. I authorize and direct 1 st Care to file a UCC lien to secure payment for services provided. I authorize and instruct my attorney to pay bills incurred by me to 1 st Care out of proceeds of any settlement or judgment. I instruct all insurance companies to pay bills submitted by 1 st Care directly to 1 st Care unless expressly stated in my insurance policy, in which case I instruct my insurance company to make checks payable to myself and 1 st Care, and to mail such payment directly to 1 st Care. In the event of any dispute arising from bills incurred by me, I direct my attorney to hold proceeds of any settlement or judgment in escrow until said dispute is resolved. I agree that this agreement will act as a lien against any settlement or judgment, and this agreement may be rescinded only by mutual consent of myself and the management of 1 st Care. Any charges incurred by me in this office are my sole responsibility, despite any insurance plan, legal involvement, or settlement. I have read and understand the HIPPA privacy policy posted in the office. All disputes arising from this agreement or professional relationship will be resolved by arbitration in accordance with American Arbitration Association rules. Any questions regarding this agreement should be addressed to a Patient Services Representative or the Office Manager and clarified, before signing it. I understand that copies of this and all documents in my medical record are available to me upon request, in accordance with HIPPA guidelines. Patient's Signature: Date: Consent to Treat Minor Child I hereby authorize the doctors and staff of 1 st Care to treat my minor child with care or diagnostic procedures deemed necessary. I agree to all terms and conditions outlined in this form. Name: Date: Signature:
Patient Health Information Consent Form
Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any
Chandler Chiropractic 333 N. Dobson Rd., #16, Chandler AZ
Chandler Chiropractic 333 N. Dobson Rd., #16, Chandler AZ 85224 480.899.9855 Name Address: City State Zip Home # Cell # Email SSN Date of Birth Age Weight Height Male Female Single Married Divorced # of
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):
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:
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
Personal Injury Questionnaire
Personal Injury Questionnaire (PLEASE PRINT CLEARLY) Date: Last Name: First Name: MI: Address: City: State: Zip: Home Phone: Cell Phone: Email: Social Security #: - - Birth Date: / / Age: Male Female Marital
INSURANCE INFORMATION
PATIENT NAME: ADDRESS: CITY: STATE/ZIP CODE: HOME PHONE NUMBER: CELL PHONE NUMBER: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: GENDER: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMPLOYER NAME:
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
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
TO ALL OF OUR NEW PATIENTS
Wiles 2310 Mildred St. W, #100C, WA 98466 Thank you for choosing Wiles Chiropractic! We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with
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:
Family First Chiropractic & Wellness Center 9445 Farnham Street, Suite 104 San Diego, CA 92123
PATIENT NAME: ADDRESS: CITY: STATE/ZIP CODE: HOME PHONE NUMBER: CELL PHONE NUMBER: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: GENDER: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMPLOYER NAME:
Weitz Sports Chiropractic and Nutrition. Ben Weitz D.C. C.C.S.P th Street, Suite 201. Santa Monica, CA Name: Referred By:
Weitz Sports Chiropractic and Nutrition Ben Weitz D.C. C.C.S.P. 1448 15 th Street, Suite 201 Santa Monica, CA 90404 310-395-3111 Name: Referred By: Other Doctors Seen For This Condition: Purpose of This
Nicholas Southworth, D.C.
Always Active, Always Improving Nicholas Southworth, D.C. PATIENT INFO Patient Name: Male [] Female [] Birthdate: / / Age: SS#: - - DL # Home Address City/State/ZIP Home Phone: ( ) Cell Phone: ( ) Would
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
What to bring to your first visit:
What to bring to your first visit: *Identification (drivers license) *Health Insurance Card *X-Rays (if taken since injury) *Police Report (auto accident) *Auto Insurance Card (yours and the drivers, if
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
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
Joint Chiropractic Case History/Patient Information
1 Joint Chiropractic Case History/Patient Information Name: Date: Social Security # Birth Date: Race: Marital Status: M S W D Address: City: State: Zip: E-mail address: Cell: Home: Work Occupation: Employer:
Health Moves. "The Way to Wellness" PATIENT INFORMATION
Health Moves "The Way to Wellness" PATIENT INFORMATION Today s Date Age Birthdate Address City State Zip Home Phone Work Phone Cell Phone Fax Email SSN Sex: M F Marital Status: Single Married Divorced
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:
HARPETH VALLEY HEALTH CENTER Tamera Thoener, FNP-C Kimin Huang, AGNP-C Wellness Practitioner Kelli Thomas
DIXON CENTER FOR INTEGRATIVE HEALTH CARE Andrew Dixon, DC Christy Diaz, DC HARPETH VALLEY HEALTH CENTER Tamera Thoener, FNP-C Kimin Huang, AGNP-C Wellness Practitioner Kelli Thomas PERSONAL INJURY OFFICE
Palmer Chiropractic. Your health is our concern. Name Address Preferred: Cell / Hm # / Wk # Address City Zip Code. Home Ph Work Ph Cell Ph
Palmer Chiropractic Your health is our concern Name Email Address Preferred: Cell / Hm # / Wk # Address City Zip Code Home Ph Work Ph Cell Ph Date of Birth Age Sex M F Marital Status S M D W Social Security
Address: City: State: Zip: Age: Birth Date: Marital Status: M S W D No. of Children. Your Employer: Occupation: Years on Job:
C O N F I D E N T I A L PAT I E N T I N F O R M AT I O N The following information is needed in order to better serve you. Please complete all questions. If you need help, please ask the receptionist.
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
Motor Vehicle Accident Questionnaire
PERSONAL INJURY PATIENT HISTORY Name Date Address Phone Cell Phone E-Mail For text reminders, your cell phone provider: Date of Birth: Social Security Number: WOMEN ONLY: Are you pregnant or is there any
Medical Information Sheet
Please use this guide as a tool to identify where you want to head with your recovery and identify areas or pieces that may be missing in your wellness. Simply check the answers that best apply to you
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:
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
Georgia Knotek D.D.S. Personalized Dental Care
Georgia Knotek D.D.S. Personalized Dental Care Name: Social Security #: Date of birth: Age: Sex: M / F Phone: Home/Cell Address: City: State: Zip Code: Email: Occupation: Employer: Business Phone: Physician:
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
First Name MI Last Name. Address. City State ZIP. Phone (H) (W) (Cell) (Please circle the preferred contact number) Address
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
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
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757 PLEASE PRINT Patient Name SS# Address City State Zip Code Birth Date / / Age Circle one: Marital Status: S/M/D/W/P How
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
PARAGON Physical Therapy, PC
WELCOME TO PARAGON Physical Therapy. Who can we thank for referring you? We appreciate you choosing PARAGON Physical Therapy, PC to be your provider of physical therapy services. If you would not mind,
Spencer Family Chiropractic
Spencer Family Chiropractic 503 W. 10 th St ~ Rome, GA 30165 ~(706) 234-3031 PERSONAL HEALTH HISTORY Welcome to our Family! Date: Patient ID# Name: Nick Names: Address: City/State/Zip: _ Home Phone: Work
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M.
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. 10801 Lockwood Drive, Suite 260 Silver Spring, Maryland 20901 (301) 439-0300 3408 Olandwood Ct., Suite 204 Olney, Maryland 20832-1367
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:
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 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:
PERSONAL INJURY QUESTIONNAIRE
LAW OFFICES OF Daniel H. Alexander A PROFESSIONAL LAW CORPORATION 901 Bruce Rd., Ste. 230 Chico, CA 95928 951 Reserve Dr., Ste. 100 Roseville, CA 95678 (800) 530-4529 (530) 891-8000 Fax (530) 891-8040
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
o 5801 Allentown Road, Suite 305 Camp Springs, MD 20746
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. o 10801 Lockwood Dr., Suite 260 Silver Spring, MD 20901 ph. (301) 439-0300 Ix. 681-1488 o 3408 Olandwood Court, Suite 204 Olney, MD 20832
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
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
EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
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. Health Information
Patient Information Patient Name: Date: Last First MI (Preferred name) Male Female Married Single Child Other Social Security #: Birth Date: Phone (Home): (Work): Ext: Cell: Email: Address: Street Apartment
Preferred Name: Social Security # Date of Birth Male Female. Contact Phone #1 #2 #3
Preferred Name: Please allow a few minutes at each visit for us to evaluate your progress and collect any necessary documentation for your billing agreement with us. Note if injury caused by: Car Accident
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: ( )
Lombardi Chiropractic and Rehabilitation Dr. Joseph P. Lombardi, D.C West 38th Street Erie, PA 16508
Lombardi Chiropractic and Rehabilitation Dr. Joseph P. Lombardi, D.C. 1430 West 38th Street Erie, PA 16508 Date Social Security # Name Birthdate: Address _ City St. Zip Home Phone Cell Phone Age Sex Height
Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions we ll be glad to help you. We look forward to
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
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
Automobile Accident Questionnaire
Londer Family Chiropractic Center Dr. Irene Dubinsky Londer 3000 Valley Forge Circle, Suite G-12 King of Prussia, Pa 19406 610-783-1311 610-783-1112 fax Automobile Accident Questionnaire Accident Information
Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)
Bellingham Arthritis & Rheumatology Center 470 Birchwood Avenue, Suite C, Bellingham, WA 98225 (P) 360-734-5754 (F) 360-734-0586 Patient Name SSN Last First M.I. Date of Birth Age Sex: Male Female Address
Vehicle Accident Report
Vehicle Accident Report Date of Injury / / Claim # First NameMI Last Name Sex M F Address City State Zip_ Home Phone Cell Phone Best contact Cell Home Date of Birth Age Marital Status (Circle) M S D W
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
MALINA CHIROPRACTIC 3826 N. Druid Hills Rd Decatur Georgia Office Fax
MALINA CHIROPRACTIC 3826 N. Druid Hills Rd Decatur Georgia 30033 Office 404-352-3609 Fax 404-325-8859 Car Accident Questionnaire Name: Age: Date of birth: LAST FIRST MIDDLE Social Security #: Male Female
Bartz Chiropractic 1316 SW 4 th Terrace, Suite 102 Cape Coral, FL 33991
Bartz Chiropractic 1316 SW 4 th Terrace, Suite 102 Cape Coral, FL 33991 Auto Accident History Date Name First Middle Last Address City State Zip Soc Sec # Home Phone Birthdate Age Cell Phone Marital Status:
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:
Automobile Accident Questionnaire Integrated Physical Medicine, LLC
Automobile Accident Questionnaire Integrated Physical Medicine, LLC Accident Information Name: Date: 1. Date of Accident: Time: a.m./p.m. 2. Driver of car: Where you were seated: 3. Owner of car: Year
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Ronald M. Yarab, Jr., M.D. Michael T. Engle, M.D. Sean T. McGrath, M.D. Patient s First Name: M.I. Last: Mr. Mrs. Miss Ms. Marital status: (circle one) Single / Married / Divorced Separated
WALL FAMILY CHIROPRACTIC CENTER
WALL FAMILY CHIROPRACTIC CENTER Dr. Michael L. Wall, D.C. 13412 Pacific Avenue Tacoma, WA, 98444 Office: (253) 531-5242 Fax: 253-537-7293 About the Patient Name: Address: City: State: Zip: Home Phone:
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 #:
The Vanguard Clinic. Check appropriate Box: Minor Single Married Divorced Widowed Separated
The Vanguard Clinic 2108 Schuetz Rd. St. Louis, MO 63146 Patient Name: : Email: SS#/SIN: DOB: Phone Number: E-Mail Check appropriate Box: Minor Single Married Divorced Widowed Separated Address: City:
ONEACCORD PHYSICAL THERAPY CASA GRANDE, GILBERT & PHOENIX, AZ REGISTRATION FORM PATIENT INFORMATION. q Mr. q Mrs.
ONEACCORD PHYSICAL THERAPY CASA GRANDE, GILBERT & PHOENIX, AZ REGISTRATION FORM Today s date: Primary Doctor: PATIENT INFORMATION Patient s last name: First: Middle: Is this your legal name? q Mr. q Mrs.
STEVENS FAMILY CHIROPRACTIC METROPOLIS AVE, SUITE 101 FT MYERS, FL (239) Patient Intake Form. Sex: Male Female.
Patient Intake Form : Name: Sex: Male Female Address: City: State: Zip: Home Phone: Cell Phone: Preferred Phone: Email Address: Social Security #: Of Birth: Occupation: Marital Status: Single Married Divorced
NEW PATIENT INFORMATION. Name: (Last) (First) (Middle) DOB: Address: City: State: Zip: Home #: Work #: Cell#: -
NEW PATIENT INFORMATION Name: (Last) (First) (Middle) DOB: Address: City: State: Zip: Home #: Work #: Cell#: E-Mail- SS#: Marital Status (S-M-Sep-D-W) Sex: (Male/Female) Age: Employer: Work Title: Name
Chiropractic Partners Phone: (919) South Park Drive, Suite 130 Fax: (919) Durham, NC 27713
Chiropractic Partners ACCIDENT HISTORY REPORT Please complete this form as accurately as possible. Your answers will help us determine whether chiropractic can help you. If we do not sincerely believe
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice.
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only
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):
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 Registration. D. INSURANCE (if applicable)
A. PATIENT Please Print Legibly Account #: Address: City: State: Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone Patient Registration DOB: SSN #: Gender: Male Female E-MAIL: Check here
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 /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth Date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
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
Symptoms From The Accident
Auto Accident Patient History Name: Date: History of the Occurrence Were you the (driver or passenger)? What type of vehicle were you in (car/truck/van/other) Was it (Your or Someone else s) vehicle? The
Georgia Foot & Ankle
Georgia Foot & Ankle PLEASE PRINT CLEARLY Today s Date / / Name Date of birth / / First MI Last SSN Marital Status M S D W Age Weight Height Male Female Address City State Zip Phone (Home) (Work) (Cell)
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Email Address Street Address City State Zip Social Security Number Cell Phone Home
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:
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):
uqua 6560 Greenback Lane, Citrus Heights, CA (916) Fax (916)
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
Lowrance Dental REGISTRATION FORM (Please Print)
Today s Date: Patient s last name: First: Middle: Lowrance Dental REGISTRATION FORM (Please Print) PCP: PATIENT INFORMATION Mr. Mrs. Miss Ms. Marital status: Single Mar Div Sep Wid Is this your legal name?
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
221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:
221 Madison Ave Morristown, New Jersey 07960 (973) 538 4444 Fax (973) 538 0420 PATIENT INFORMATION Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal
NEW PATIENT INTAKE FORM Patient Name: Date:
NEW PATIENT INTAKE FORM Patient Name: Date: 1. Is today's problem caused by: Auto Accident Workman's Compensation 2. Indicate on the drawings below where you have pain/symptoms 3. How often do you experience
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
PATIENT INFORMATION Patient s Full Name: (First) (Middle) (Last) Birth date: Age: Race: Sex: [ ] Female [ ] Male Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed SS# Address: City: State:
*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
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
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
MESSIEH ORTHOPEDICS Page 1 MICHAEL S. MESSIEH, M.D. DEMOGRAPHICS/INSURANCE INFORMATION. Patient name: Date of Birth: / / SS#: Race:
MESSIEH ORTHOPEDICS Page 1 MICHAEL S. MESSIEH, M.D. DEMOGRAPHICS/INSURANCE INFORMATION Date: Patient name: Date of Birth: / / SS#: Race: Ethnicity: Language: Home address: City: State: Zip code: Email:
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
Physical Therapy Services of Ottawa County Patient Registration Form
Physical Therapy Services of Ottawa County Patient Registration Form Personal Information Name Age Sex Date of birth Single Married Widowed Address City State Zip Home phone Cell phone Work phone Email
PERSONAL INJURY INTAKE & QUESTIONAIRRE
Dr. Donald Shiflet Chiropractic Physician The Back Alley Chiropractic & Massage 10515 N Oracle Rd Ste 167, Oro Valley AZ 85737 Phone (520) 877-2666 Fax (520) 877-9183 Email: thebackalleychiro@yahoo.com
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided. Last Name: First Name: Primary Care Physician: Referring
Stinnett Chiropractic we correct pinched nerves
Stinnett Chiropractic we correct pinched nerves Date: First Name: Last Name: Address: City: State: Zip: Home Phone: Cell Phone: Gender: Male Female Birth Date: Marital Status: Single Married Divorced Widowed
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
LENNOX SPECIALTY GROUP
LENNOX SPECIALTY GROUP Great expectations, Great results New Patient Intake Forms Your completed intake paperwork helps our physicians and other providers get to know you and your medical history better.