Are you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure
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1 Patient s Full Name: of Birth: Age: Address: City: State: Zip: Patient Social Security #: Gender: Height: Weight: Cell Phone: Other Phone: Preferred appointment reminder: ( )Text: Cell Phone Provider: ( ) ( )Neither Occupation: Employer: Status: ( ) Employed ( ) Full-Time Student ( ) Part-Time Student ( ) Retired ( ) Unemployed Who may we thank for referring you? Smoking Status: ( ) Current Daily Smoker ( ) Current Social Smoker ( ) Former Smoker ( ) Never Smoker Smoking Start : End : In effort to quit smoking, I am currently taking: What medications are you currently taking? Are you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure Have you had previous Chiropractic or Acupuncture: ( ) Yes ( ) No If yes, for what problem? Doctor s Name: City/State: What type of care are you interested in? ( ) Chiropractic ( ) Acupuncture ( ) Massage ( ) Home exercises ( ) Other: Is today s visit due to a work related injury? ( ) Yes ( ) No of Injury: Is today s visit due to an auto accident? ( ) Yes ( ) No of Injury: (If yes to either question above, please check with receptionist, additional information may be needed) Emergency Contact Relationship Phone Primary Insured Name, Relationship, of Birth: *Please present your photo ID and insurance card to front desk receptionist*
2 In general, would you say your health is (check one): ( )Excellent ( ) Very Good ( )Good ( )Fair ( ) Poor PAST HEALTH HISTORY: 1. Have you ever had a stroke or issues with blood clotting? ( )Yes ( ) No If yes, when? 2. Have you recently experienced dizziness, unexplained fatigue, weight loss, or blood loss? ( )Yes ( )No If yes, when? 3. Have you ever had any major illnesses, injuries, hospitalizations, car accidents, surgeries, etc? Injury/Illness/Accident/Surgery Treatment Results SYSTEMS REVIEW QUESTIONS: Do you, or have you ever, had any problems with the following areas? (Y for yes, X for no) 1. Eyes 2. Ears, Nose, Mouth, Throat 3. Heart 4. Lungs/Breathing 5. Intestines/Bowels 6. Urinary 7. Muscles 8. Nerves 9. Joints/Bones 10. Skin 11. Internal Organs 12. Blood 13. Allergies 14. Psychological 15. Eating Disorder For Females Only: 16. Gynecological/Menstrual 17. Breast For Males Only: 18. Prostate/Penile Please explain: Social History: Recreational Activities/Hobbies: Have these activities been limited by your pain? If yes, describe: Yes No Do you exercise? times/week Do you consume alcohol? How many drinks per week? Do you eat a balanced diet? If no, explain: Do you get adequate sleep? How many hours per night: Is work stressful to you? If yes, explain: Is family life stressful to you? If yes, explain: Do you use recreational drugs? If yes, explain: Do you drink enough water daily? How much water do you drink per day? oz/day Do you consume caffeine? How much? oz/day Are you training or working towards for a specific race, event and/or goal?
3 What problem brings you to us today? When did your symptoms begin? Have you had this problem before? ( )Yes ( )No Explain: Previous treatment from another professional for this condition? ( )Yes ( )No; Send Notes ( ) Yes ( )No If yes, please explain diagnosis and treatment from another professional for this condition Was the onset: ( ) Gradual ( )Sudden; Since its onset, pain has gotten: ( ) Better ( ) Worse ( )No Change Please describe what caused the pain: What aggravates this condition? What decreases the symptoms/pain? Does this pain interfere with your sleep? ( ) Yes ( )No Does it interfere with daily activities ( ) Yes ( )No Is your pain worse in the: ( ) AM ( ) PM ( ) Constant ( ) With Activity: Have you detected any possible relationship of your current complaint with any of the following: ( )Muscle Weakness ( )Bowel/Bladder ( )Digestion ( )Cardiac/Respiratory ( ) Other: PAIN CHART: Please mark areas of pain using these codes: +++ Burning ### Dull/Ache *** Numbness/Tingling === Throbbing 000 Sharp/Stabbing SEVERITY OF PAIN: Please list area of pain & write a number 1-10 which represents the intensity of your pain (1= minor pain, 10=unbearable): 1. Complaint: At worst: /10 At best: /10 Typical: /10 2. Complaint: At worst: /10 At best: /10 Typical: /10 3. Complaint: At worst: /10 At best: /10 Typical: /10 Do you require special care, or have any concerns that might affect your treatment or recovery?
4 OUR MISSION STATEMENT Our MISSION is to provide the best care possible to every patient which is accomplished by supporting our staff and providers in every way possible to allow them to practice efficiently and dedicate their time to the individual needs of the patient. INFORMED CONSENT I understand this Facility, its doctors & staff are accepting my case based on examination findings and believe the outlined treatment should produce change and/or improvement. However as with any diagnostic test, procedure, examination or doctor s care, a guarantee of improvement or complete recovery cannot be made and it is even possible that no change occur. I further understand that in the practice of medicine, chiropractic, massage therapy, acupuncture and physiotherapy there are some risks including but not limited to fractures, disc injuries, strokes, dislocations, sprain-strains, drug interactions & reactions and/or other injuries or side effects which cannot be predetermined. I do not expect the doctor/provider to be able to anticipate and explain all risks and/or other complications, and I wish to rely on the doctor/provider to exercise judgment during the course of the procedure(s) which the doctor/provider feels at the time is in my best interest. In addition, because psycho-social, spiritual, and cultural values affect a patient s response to care, patients are allowed to express and follow spiritual beliefs and cultural practices that do not harm others or interfere with the planned course of treatment. Patients have the right to refuse treatment, but must be aware of the probably consequences of refusing treatment and/or failing to cooperate with the prescribed treatment. Should you refuse and/or fail to comply with prescribed treatment your provider will discuss specific consequences with you. Therefore I give my full consent to the doctor/provider to render treatment on me or the minor whom I am legally responsible by a health care provider of this Facility. ASSIGNMENT OF BENEFITS- AUTHORIZATION AND LEIN I, the assignee, being the patient or legal guardian for the said minor listed below, do herby irrevocable authorize, direct, assign and give full lien to the office named above and listed below, hereinafter referred to as the Facility against any and all insurance benefits, proceeds of any settlement, judgment or verdict which may be paid to the undersigned as a result of the injuries or illness for which I have been treated by the Facility. I, the assignee, further authorize any and all insurance company, attorney and any & all third party payer to pay directly to the Facility all sums of money due them for any and all services rendered to me or minor by whom I am responsible for by reason of accident, illness and by any and all reason of any other bills that are due or may become due, and to withhold such sums from any health & accident, workers compensation and or including all insurance or third party benefits. Assignee agrees that this Facility & staff may deliver medical records, consultations, depositions and/or court appearances which must be paid in full in advance and authorizes this Facility to release any information pertinent to said health care any insurance company, adjuster, attorney or legal service bureau to facilitate collections under the terms of this document. Assignee grants the Facility a full power of attorney to endorse and/or sign my name on any and all checks for payment of any indebtedness owed this office & assignee. INSURANCE BENEFITS- CREDIT POLICIES- PAYMENT TERMS & CONDTIONS 1. As a courtesy, the Facility will obtain a verification of applicable insurance benefits as they are quoted to us but some third party payers mis-quote benefits, coverage, and liability. Our Facility and staff are not responsible for what third party payer and/or representative may tell us. Any contractual, written, verbal or other obligations or arrangements between you and an attorney, insurance company, liable or third party payer are between you and said person. 2. Our Facility will file initial insurance claims for you. Secondary claim submission and/or additional reports or documents sent for your benefit may result in additional filing medical report charge which you are responsible to pay. 3. Co-pays, deductibles and all non-covered service charges are due the day the service is rendered. 4. Patients are responsible for charges on all service(s) and/or product(s) which may exceed the maximum allowable and/or when a third party and/or insurance carrier does not reimburse this Facility enough to meet our cost of service. 5. All account balances, including automobile and work injury claims must be paid in full within 90 days of treatment. Patients are fully responsible for all money owed this office and such payment is not contingent on any settlement, claim, judgment, or verdict by which they may eventually recover said fee and it is also regardless of any attorney liens or pending settlement(s). If a third party payer fails to pay said balance in full within the 90 day period, the patient must pay the balance in full. Assignee if fully responsible for all money owed this Facility for any and all treatment, products & services rendered to the patient or minor shown below. 6. There is a $25 no show fee applied to all appointments that have not been cancelled within 24 hours. Text message or reminders are available to avoid missed appointments. 7. Returned checks, debit & credit charges made payable to this Facility for insufficient funds, stop payments or other reasons of non-payment will be assessed a $30.00 charge. 8. Acupuncture along with associated exams and massages are cash services in our office and will not be submitted to insurance. Payment is due at time of service. Acupuncture sessions bought in packages are non-refundable and non-transferable. 9. Even if we are in network with your insurance company, they may determine they may only cover acute care. If you are coming in for maintenance or wellness care, they may deny coverage, leaving you to pay the cash price of $50 a visit. I understand & agree to the above statements. Any questions I have had regarding the above have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely Patient s Signature
5 Patient Acknowledgement and Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent for Use of Health Information 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. Patient s Signature If patient is a minor or under a guardianship order as defined by State law: By Signature of Parent/Guardian I furthermore hereby authorize Clayton Chiropractic Center to release my medical information to the following person(s)/entities including primary care, OB/GYN, orthopedist, physical therapist, other medical doctor to provide integrated care:
Olde Naples Chiropractic Health Center
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
1. PATIENT INFORMATION
Runnels Chiropractic 32 South 9 th Street - Richmond, IN 47374 (765) 96 CHIRO (24476) www.runnelschiro.com 1. PATIENT INFORMATION Today s _ Full Name SSN Age DOB Address City State Zip Height Weight Race
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
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:
THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Employer s Name School
THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Sex: M F Employer s Name School Contact Information: Mailing Address City State Zip
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
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
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
FINANCIAL POLICY & AGREEMENT
BACK TO HEALTH CHIROPRACTIC WELLNESS CENTER, P.C. 10990 Chicago Drive Zeeland, MI 49464 (616) 546-3500 FINANCIAL POLICY & AGREEMENT SOURCE OF PAYMENT The Financial Policy of Back to Health Chiropractic
WELCOME TO WINDROSE CHIROPRACTIC
WELCOME TO WINDROSE CHIROPRACTIC Please complete the following information. We appreciate your cooperation! Chiropractic Case History/Patient Information (Please print) Date: Patient # Doctor Name: Social
Northwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR
rthwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR 97035 503-850-4526 DEMOGRAPHCS Last Name: First Name: MI: Date of Birth / / Gender: SS#:
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
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
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):
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
Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ 85260 480-443-2584 www.wellnessdoc.com Date Home Phone Work Phone Cell # Patient e-mail: Last Name First Name Street Address City
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
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
To all of our new patients
ATLAS FAMILY Thank you for choosing Atlas Family Chiropractic. We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your
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:
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
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:
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:
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
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
Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -
New Patient Forms Today s Date: Name (Last, First, MI): Date of Birth: Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): _ Home Phone: _ ( ) Cell Phone: _ ( ) Work Phone:
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
Spinal & Sports Care Clinic, PS E Sprague Ave., Spokane Valley, WA 99216
Spinal & Sports Care Clinic, PS 12905 E Sprague Ave., Spokane Valley, WA 99216 First Name (Legal): (MI): Last Name: Social Security Number: / / Birth Date: / / Married! Single! Other! Mailing Address:
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
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):
ACIC PHYSICAL THERAPY
ACIC PHYSICAL THERAPY PATIENT INFORMATION NAME (first, last): DATE: HOME PHONE: CITY: STATE: ZIP: SSN: DRIVER S LICENSE #: EMAIL: SEX: M F DATE OF BIRTH: AGE: DATE OF INJURY : CAUSE OF INJURY: REFERRING
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
Have you had previous Chiropractic Care: Yes No If yes, for what problem? Doctor s Name: City/State:
Patient s Full Name: Age: Sex: Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-Mail Address: Date of Birth: / / Male Female Patient Social Security #: - - Social Security
Automobile Accident Questionnaire
Automobile Accident Questionnaire Date of Accident: Time of Day: Please explain in detail: Name of driver in your vehicle: Name of driver in other vehicle: Type of vehicle you were driving: How many passengers
Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX (972)
Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX 75093 (972) 265-8100 Name: Date: Address: City State Zip E-mail: Cell #: Home #: Work #: Birth Date: S.S.#: Single Married Divorced Widowed
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
SHOOK FAMILY CHIROPRACTIC, INC.
PATIENT APPLICATION FOR TREATMENT PLEASE CIRCLE THE TYPE OF CARE DESIRED: TEMPORARY LASTING RELIEF DATE: Name: SSN: Date of Birth: Address: City: State: Zip: Cell: Home: Work: Name of Spouse: Ages of Children:
CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION
PATIENT INFORMATION INSURANCE INFORMATION Patient Name: : Address: Birthdate: Responsible for this account: Relationship to Patient: Insurance Co.: Group #: ID #: SS Number: Sex: M F Age: Employer/School:
PATIENT HEALTH RECORD CHILD
ABOUT THE CHILD Name Address City State Zip Home phone Birth date SS# Age Gender Weight ABOUT THE PARENT Name Employer Work address Work phone Cell Type of work E-mail address Social Security # PATIENT
PATIENT HEALTH RECORD CHILD
ABOUT THE CHILD Name Address City State Zip Home phone Birth date SS# Age Gender Weight ABOUT THE PARENT Name Employer Work address Work phone Cell Type of work E-mail address Social Security # PATIENT
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
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
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
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):
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
NEW PATIENT INFORMATION FORM
3271 N. Milwaukee St. Boise, ID 83704 tel: (208) 629-5374 fax: (208) 629-5394 www.theicim.com NEW PATIENT INFORMATION FORM Personal: Last Name: First Name: Middle Initial: : Address: City: State: Zip:
List the names of any relatives that have or have had a similar problem. CMS requires providers to report both race and ethnicity
APPLICATION FOR TREATMENT Date Name: Age: Date of Birth: Address: City State ZIP Phone: Home Work Cell Email: Preferred method for appointment reminders: [] Email []Phone [] Mail Marital Status: [] Married
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(
Workers Compensation: Please be advised that in the event your claim is denied, you are financially responsible for all charges.
Welcome to Lake Burien Physical Therapy, Inc (LBPT). We bill your insurance company as a courtesy to you. We verify your insurance coverage; however, this is not a guarantee of payment. Please keep in
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
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
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
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
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: ( )
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
Advanced PT, LLC 200 W Douglas Ave, Ste 1040 Wichita, KS (866)
200 W Douglas Ave, Ste 1040 Wichita, KS 67202 (866) 412-5554 Welcome to Advanced PT, LLC. We are honored that you have chosen us as your therapy provider. Our goal is to provide the highest quality of
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
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
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
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
Sammy Lerma III, M.D. P.A. History and Physical Name: DOB: Age:
History and Physical Name: DOB: Age: Reason for Visit : Current Medications: Previous Hospitalizations: Last Physician's Name: Previous Surgeries: Reason for Changing Physicians: Current Specialists: Medication
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:
Name: Date of Birth: Sex: Office: Date:
Patient Information Name: Date of Birth: Sex: Office: Date: Address: City: State: Zip: Social Security Number: Home Phone: Cell Phone: Email: May we leave a message? Email? Martial Status Emergency Contact
Client Information Juneau Physical Therapy
Client Information Patient Name Date of Birth Social Security # Sex F M Mailing Address City State Zip Home Phone Cell Phone Work Phone Email Address (optional) Patient Employed by Emergency Contact Relationship
New Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
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 #: (
PATIENT INFORMATION. Street address: Social Security no.: Home phone no.: ( ) City: State: ZIP Code:
Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Married / Divorced / Separated / Widow Is this your legal name? If not, what
Registration Information
Nevada Spine Center, LLC Registration Information Date Chart# D.O.B 10195 W. Twain Avenue Suite B Las Vegas, NV 89147 Patient Name SSN: Employer Drivers License # Required by the State of Florida Agency
SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
Patient Name: Date of Birth: / / Last First Day Month Year Address: City: Home Tel: Other Tel: Postal Code: *E-mail: Family Physician: Do you have a Doctors referral? How did you hear about us? If so,
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
1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND (701)
AKER CHIROPRACTIC Dr. JaNyne Aker, D.C. 1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND 58078 (701) 356-4900 PATIENT INFORMATION: TODAY S DATE: / / Name First MI Last Address City
Last Name First Name M.I. Street Address City State Zip. Home Phone ( ) Cell Phone ( ) Work Phone ( ) Emergency Contact: Name/Relation Phone Number(
TODAY S DATE Last Name First Name M.I. Street Address City State Zip Home Phone ( ) Cell Phone ( ) Work Phone ( ) Emergency Contact: Name/Relation Phone Number( ) Social Security Number - - Date of Birth
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
Personal Medical Race:
PATIENT HISTORY Are you here for: Glasses exam Contacts Other Reason Name Male Female Address Date of Birth City State Zip List ALL insurances How much is your co-pay? Are you the Primary Insured or are
Physical Therapy with care and knowledge
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?
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):
BenchMark Rehab Partners Welcome to
BenchMark Rehab Partners Welcome to At BenchMark Rehab Partners we believe communication is essential to achieving the best possible patient outcomes. Understanding your needs and expectations is essential
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:
First Name: Last Name: Initial:
Patient Information Sheet Please complete the entire form First Name: Last Name: Initial: Address: City: State: Florida Zip Code: Home: ( ) Work: ( ) Cell: ( ) 420 South Dixie Hwy, Suite 4D Email: Gender:
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
CLEAR CHOICE CHIROPRACTIC CHILDREN S HEALTH HISTORY FORM
CLEAR CHOICE CHIROPRACTIC CHILDREN S HEALTH HISTORY FORM Today s Date ABOUT THE CHILD Name Age Date of Birth Gender M F Height Weight Home Address City State Zip Names and Ages of Siblings Parent A Name
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:
For your convenience, please schedule your appointments two weeks in advance.
Welcome! Welcome to Rebound Physical Therapy. We are pleased you have selected us for your physical therapy services. We will bring you back to a healthy functional and recreational level and educate you
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE We realize that this is your first visit to our office, and our past experience has shown us that new patients have many unanswered questions on their minds. Our staff will attempt
If patient is under 18 y/o, name of Parent/Guardian: Relationship to Patient: Address: (street) (city/state) (zip code)
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
Patient Health Summary
Patient Health Summary Patient Name: Birthdate: / / Sex: M F Address: City: State: Zip: CIRCLE which telephone # to leave appointment reminders or health related messages: Home: Work: Cell: Do you give
APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation
APM PATIENT INFORMATION Date: / / Name: / / (Last) (First) (MI) Date of Birth / / SS# - - Sex: q Male q Female Address: City State Zip Home Phone # ( ) Work Phone # ( ) Circle preferred number for communication
Patient Information. Who is your primary care physician? Phone:
Patient Information Date: Patient Name: Name you go by: Street Address: Mailing Address (if different): City, State, Zip code: Date of Birth: Sex: M / F Marital Status: Single / Married / Divorced / Widowed
GIVE US STRENGTH PHYSICAL THERAPY
GIVE US STRENGTH PHYSICAL THERAPY Thank you for choosing Give Us Strength Physical Therapy for your rehabilitation needs. PATIENT INFORMATION: Name (Last, First, Middle Initial): DOB: Social Security Number:
Orange N. Harbor Blvd., Suite B Fullerton, CA Phone: Fax: New Patient Form. Address: City: State: Zip:
, CA 92866 New Patient Form New Patient: HMO PPO Medicare Work Comp Lien Other Name: Date: Home Phone: Cell: Work: Email: Social Security: DOB: Gender: Drivers License #: Referring Physician: Phone: Primary
BACK-HEALTH CHIROPRACTIC INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC THIS SECTION REFERS TO PATIENT ONLY
INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC PATIENT THIS SECTION REFERS TO PATIENT ONLY Patient: LAST FIRST MIDDLE Address: City, State, Zip: Cell Phone ( ) of birth Male Female Social
Markley Chiropractic & Acupuncture, L.L.C W Baker St Plant City, FL Patient Name: Nickname/Preferred Name:
New Patient Information PLEASE Welcome! PRINT Please CLEARLY: allow our staff to photocopy your driver s license & insurance Today s card Date: (if applicable) / /20 Patient Name: Nickname/Preferred Name:
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.
Informed Consent for Physical Therapy Services
Informed Consent for Physical Therapy Services The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative
Patient Name: Male Female Married Divorced Widowed Single. SSN: Date of birth: Address: Phone: (home) (cell) (other) Emergency contact name:
Patient Information: Patient : Male Female Married Divorced Widowed Single SSN: of birth: Address: Phone: (home) (cell) (other) Emergency contact name: Relationship to patient: Emergency contact phone:
City: State: Zip: Home ( ) Cell ( ) Work ( ) Who Referred You? Phone ( ) Address: City: State: Zip:
Today s : First Name: M.I. Last Name: Address: City: State: Zip: Apt Home ( ) Cell ( ) Work ( ) Email: of Birth: Marital Status: S M D W Sex: F / M Social Security # - - Who Referred You? Phone ( ) Address:
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
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:
Patient Information. Patient Name: (Last, First, MI) DOB: / / Home address: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) -
Patient Information Patient Name: (Last, First, MI) DOB: / / Home address: Mailing address: (if diff) Email Address: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Employer: Employer Phone: ( )