Aspen Chiropractic & Wellness

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Aspen Chiropractic & Wellness"

Transcription

1 WELCOME TO OUR OFFICE We are committed to providing you the best of care and are pleased to discuss our professional fees with you at any time. Please ask any questions you may have regarding our fees or your responsibility in complying with our financial policy and/or procedures. Co-payment/Cash: Payment is due when services are rendered. MasterCard, American Express, checks, and cash. We gladly accept Visa, Insurance Patients: Professional services are rendered and charged to your insurance on your behalf. Any services not covered by your insurance are ultimately your responsibility and may have to be paid by you at the time of service. Deductibles are the patients full responsibility. If you fail to keep your appointments or you discontinue care for any reason other than discharge by the Doctor, the bill is due and payable by you in full immediately, regardless of any insurance claims submitted. Our office accepts billing for Individual or Group insurance policies. Missed Appointments: A $25.00 fee will be charged to the patient for appointments cancelled without a 24-hour notice. Collection/Attorney Fees: I agree to pay all costs of a collection agency if necessary, not to exceed 25% of the principle to obtain payment in the event that legal action should become necessary to collect an unpaid balance due for medical services. I agree to pay reasonable attorney s fees or other such costs as the court determines proper. Limited release of Medical Information: I authorize Aspen Chiropractic & Wellness to make inquiries and to release any pertinent information to any insurance company, adjuster or attorney to facilitate collection under these circumstances. Assignment of Cause of Action: In the event that any insurance company or other third party obligated to make such payment to me or to Aspen Chiropractic & Wellness for the charges made for these services refuses to make such payment on demand, I hereby assign, transfer, and convey to Aspen Chiropractic & Wellness any and all cause of action that might exist in my favor against any such company or person. I authorize Aspen Chiropractic ic & Wellness to prosecute said action in my name or their name to collect fees due for care rendered and legal expenses, and to resolve said claims as they see fit. By signing this statement, I am agreeing to all above notices. Signature Date

2 General Information Aspen Chiropractic & Wellness Patient Information Thank you for choosing Aspen Chiropractic and Wellness. Please use black ink to fill out forms. Please don t hesitate to ask if you need assistance. Name: Date: S.S. # First M.I. Last Address: City: State: Zip: Birth date: / / Gender: Female Male Hm Ph: ( ) Cell Ph: ( ) Wrk Ph: ( ) Status: Single Married Widowed Separated Divorced Minor Patient Employer/School: Occupation: Employer/School Address: City: State: Zip: Spouse/Parent s Name: Employer: Wrk Ph: ( ) Person to contact in case of emergency: Ph: ( ) to patient: _ Insurance Information Who is responsible for this account: to Patient: Insurance Company: Policy #: Group#: Is patient covered by additional insurance? Yes No If yes which Insurance Company: Policy #: Group#: Consent to Treat By signing below I am indicating that the above information is correct. I also give the doctors and staff at Aspen Chiropractic and Wellness permission to treat my condition as deemed necessary. Patient Signature / Guardian Signature Date

3 Past Medical History (Female) Age Menses started: Last Menstrual period (date): Number of days between periods: is your cycle normal from month to month Yes No Circle what best describes changes: [Intervals between cycles] [Flow heavier or lighter] [PMS symptoms worsening] [Spotting before or after cycles] If none above apply; explain changes Date of last PAP smear: any history of abnormal PAP smears? Yes No Outcome Have you had a mammogram? Yes No Date Normal: Yes No if no explain Have you had a Bone Density Scan? Yes No Date Findings: [Normal] [Osteopenia] [Osteoporosis] Have you had a colonoscopy? Yes No Date Findings: Have you had an endometrial Ablation Yes No Have you had a Hysterectomy? Yes No --- If so, you still have your ovaries? Yes No Are you interested in bio-identical hormones? Yes No Exercise Routine Number of days per week Do you have an eating disorder? Yes No Bulimia Anorexia Overeating Major Hospitalization/accidents/serious illnesses Surgical History: Gallbladder Appendix T & A Hysterectomy Ovary removal: R/L Other: Is there any Immediate Family History of any of the following? FMH: Cancer Diabetes High Blood Pressure Stroke Heart attack High Cholesterol Stress Factors: Work s currently Flow infections Yeast BV Other Ectopic pregnancies past currently Recurrent UTI s past currently Ovarian cysts past currently STD s past currently Uterine fibroids past currently Pelvic Inflammatory past currently Disease (PID) Is there any Family History of any of the following? (Please check) Breast Cancer Uterine Cancer Ovarian Cancer

4 Aspen Wellness Center Women Evaluation Women Intake Form Name: Today s Date: Allergies to medications? Yes No What is the reason for your visit today? C/C: Patient here for a wellness evaluation, and presents with the following symptoms: Circle the symptoms that are applicable to you: Hot flashes Swollen breasts/lump Loss of muscle Night sweats Frequent Headaches Muscle weakness Sleep issues Vaginal dryness Dry skin/skin thinning/fingernails breaking Anxiety Nervousness Depression Memory loss/brain fog Muscle and joint pain Weight gain difficulty losing weight cellulite Get sick more often or increasing allergy symptoms Mood swings Feeling overwhelmed Low energy Hair loss/facial hair Restless Leg Syndrome Work outs are a struggle or longer to recover Heavy menstrual flow Painful intercourse Bloating frequent episodes of constipation or loose stools Frequent episodes of Constipation or loose stools Low libido or Inability to have orgasm Feeling cold often Food cravings sweets carbs - salt Urinary urgency or frequency Have you been told you have any type of medical condition/disorder? Yes No If so what type of condition? Depression/Anxiety Diabetes Heart disease High blood pressure High Lipids Asthma Blood Clots Migraines Liver Disease DES exposure Seizure other Are you under treatment for it? Yes No If so what type of treatment (circle applicable) Medication Physical Therapy Counseling Acupuncture Other

5 List current Prescriptions and dose: Medications Name Dose (You may attach list) Herb Products/dietary supplements: (You may attach list) Are you currently on any type of Hormonal Replacement Therapy (HRT)? Yes No If so, what type and what dosage are you currently taking: _

6 Getting To Know You Name: Whom may we thank for referring you? Where are you from? Are you? Married Single Partner What is your Occupation? Do you have any children? Yes No Girl(s) Boy(s) What are your hobbies(s)? I have received a copy of the Notice of Privacy Practices. Patient Signature Date

7 Others Involved in My Healthcare Patient Name: _ ID Number: You, Dr. Shane McCall, MAY discuss all aspects of my healthcare with: As the patient, you may also request that any part of your Private Health Information (PHI) not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your physician does agree to the requested restriction, we may not or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You, Aspen Chiropractic & Welness, MAY NOT discuss any aspect of my health care with the following person/people, unless it is needed to provide emergency treatment. Signature of Patient or Legal Representative Date: (You have the right to rescind any part of this authorization with written notice.)

Female New Patient Package

Female New Patient Package Female New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank

More information

Patient Registration Form

Patient Registration Form Patient Registration Form Name (Last, First, Middle) SSN# Age Marital Status Maiden Name Address Patient Home Phone Patient Business Phone Patient Cell Phone Patient E-mail Patient Occupation Business

More information

HEALTH ADDITIONS, PLLC

HEALTH ADDITIONS, PLLC Check all that apply PATIENT PROFILE- PLEASE PRINT CLEARLY-PAGE 2 Patient s Last Name First Primary Care Physician: Address: Phone Number: Are you allergic to any medications? Y/N If yes, please list them:

More information

OB-GYN Associates, P.A.

OB-GYN Associates, P.A. Physician PATIENT INFORMATION Patient Name (First, M.I., Last) Social Security # Date of Birth Marital Status Address - - / / Apt # - Lot # - Bldg # - C/O City State Zip Code Home Phone Who referred you

More information

Congratulations on taking a positive step toward improving your health! Enclosed please find a New Patient Packet which includes:

Congratulations on taking a positive step toward improving your health! Enclosed please find a New Patient Packet which includes: Congratulations on taking a positive step toward improving your health! Enclosed please find a New Patient Packet which includes: Medical History Intake Form. Once completed, please return the form and

More information

WELCOME TO COLLEGE HEIGHTS OBGYN ASSOCIATES

WELCOME TO COLLEGE HEIGHTS OBGYN ASSOCIATES WELCOME TO COLLEGE HEIGHTS OBGYN ASSOCIATES We are pleased you have selected College Heights OBGYN Associates for your obstetrical / gynecological care. Meeting a new medical provider can cause anxiety

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM PATIENT REGISTRATION FORM Last Name: First Name: Middle Initial: Street Address: City: State: Zip Code: Date of Birth: E-Mail Address: Daytime Phone: Evening Phone: _ Emergency Contact Name & Phone Number:

More information

Male New Patient Package

Male New Patient Package Male New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank

More information

Acknowledgement of Receipt of Notice of Privacy Practices

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

More information

HORMONE BALANCE TEST FOR WOMEN

HORMONE BALANCE TEST FOR WOMEN HORMONE BALANCE TEST FOR WOMEN Please Note: The information contained in, and the results of, this Hormone Balance Test are not intended to replace a one-to-one relationship with a qualified health care

More information

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in

More information

PATIENT REGISTRATION

PATIENT REGISTRATION PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital

More information

Female New Patient Package

Female New Patient Package Female New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. We

More information

PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:

PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION: PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE

More information

North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email

North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:

More information

Female Patient Questionnaire & History

Female Patient Questionnaire & History Female Patient Questionnaire & History Name: (Last) (First) (Middle) Today s Date: Date of Birth: Age: Weight: Occupation: Home Address: City: State: Zip: Home Phone: Cell Phone: Work: E-Mail Address:

More information

Steven G. Trostel, M.D., P.A.

Steven G. Trostel, M.D., P.A. NAME: / / FIRST MIDDLE LAST DATE OF BIRTH ADDRESS: STREET CITY STATE ZIP PHONE (PLACE CHECK WHERE WE MAY LEAVE A MESSAGE, YOU CAN PICK MORE THAN ONE) HOME WORK CELL MARITAL STATUS: SINGLE MARRIED DIVORCED

More information

1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840

1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible

More information

Name: DOB: Date: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Emergency Contact Name: Emergency Contact Phone:

Name: DOB: Date: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Emergency Contact Name: Emergency Contact Phone: Women s Health Care Group of PA Patient Medical History Please complete the following information as accurately as possible. Your answers on this form will help your provider understand your medical concerns

More information

Female Testosterone and/or Estradiol Pellet Insertion Consent Form. Name: Today s Date: (Last) (First) (Middle)

Female Testosterone and/or Estradiol Pellet Insertion Consent Form. Name: Today s Date: (Last) (First) (Middle) Female Testosterone and/or Estradiol Pellet Insertion Consent Form Name: Today s Date: (Last) (First) (Middle) Bio-identical hormone pellets are concentrated hormones, biologically identical to the hormones

More information

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit. Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)

More information

RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form

RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital

More information

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot. : 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:

More information

Carter Physiotherapy, PLLC. Patient Contact Information

Carter Physiotherapy, PLLC. Patient Contact Information Carter Physiotherapy, PLLC Patient Contact Information Patient Name Today s Date Address City State Zip Code DOB Gender Marital Status Occupation Home Phone Work Cell Other Fax Email Employer Work Address

More information

Personal Injury Questionnaire

Personal Injury Questionnaire Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer

More information

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia

More information

The menopausal transition usually has three parts:

The menopausal transition usually has three parts: The menopausal transition usually has three parts: Perimenopause begins several years before a woman s last menstrual period, when the ovaries gradually produce less estrogen. In the last 1-2 years of

More information

Mountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION

Mountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION Mountain View Natural Medicine Lorilee Schoenbeck ND, PC Jessica Stadtmauer ND Dana Dabransky ND Sara Norris ND 185 Tilley Dr. Suite 51 S. Burlington, VT 05403 Phone: (802) 860-3366 Fax: (866) 440-8220

More information

Medical History Questionnaire

Medical History Questionnaire Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of

More information

BIOIDENTICAL HORMONE REPLACEMENT THERAPY

BIOIDENTICAL HORMONE REPLACEMENT THERAPY BHRT Data supports* that hormone replacement therapy with pellet implants is an effective bio-identical method to deliver hormones in both men and women. Implants, placed under the skin, consistently release

More information

Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.

Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H. Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex

More information

BHRT HEALTH HISTORY - Female

BHRT HEALTH HISTORY - Female BHRT HEALTH HISTORY - Female Gynecological History 1. What is your height? Current weight? 2. How old were you when you had your first period? 3. What is your current menopausal status? Pre-menopausal

More information

Atlantis Physical Therapy Associates

Atlantis Physical Therapy Associates Atlantis Physical Therapy Associates Date Called/Walk-In: Appointment Date: Time: PT/OT: Diagnosis/ICD9/Body Parts: Frequency & Duration: X Referring Doctor: Dr. Phone#: Fax: NPI: Addresss: Ins Type: (Circle

More information

Arrive 15 minutes before your scheduled appointment time.

Arrive 15 minutes before your scheduled appointment time. Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist

More information

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A: Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:

More information

Grey Physical Therapy and Sports Medicine Center

Grey Physical Therapy and Sports Medicine Center Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First

More information

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

More information

NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280

NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate

More information

DOB Primary Care Physician

DOB  Primary Care Physician a division of Women s Health Partners of California 110 Tampico Suite 210 Walnut Creek, CA 94598 Tel 925-935-6952 Fax 925-935-1396 Email Info@Leachobgyn.com Please PRINT and complete all sections below.

More information

AON Physical Therapy & Wellness

AON Physical Therapy & Wellness AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?

More information

Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown)

Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Patient Name: Date of Birth Mailing Address: City: State Zip: Apt/Ste/Unit/Bldg Primary Number:

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:

More information

CONSENT FOR MEDICAL TREATMENT

CONSENT FOR MEDICAL TREATMENT CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern

More information

RENAL EVALUATION or CONSULTATION

RENAL EVALUATION or CONSULTATION Please bring your insurance cards, recent medication list, recent testing (blood and urine tests, renal scans/ultrasounds), insurance referrals (if necessary), and a prescription from your referring physician.

More information

Patient Information. Welcome. Here s what you can expect on your first visit:

Patient Information. Welcome. Here s what you can expect on your first visit: Patient Information Welcome Here s what you can expect on your first visit: 1. You will provide us with your health information 2. The Patient Coordinator will introduce you to your Doctor or Therapist

More information

Healing Hormones. Episode 1

Healing Hormones. Episode 1 Healing Hormones Episode 1 7 Hormone Producing Glands Ovaries - Estrogen, Progesterone Adrenals - Cortisol, Cortisone, DHEA, Pregnenolone, Testosterone Pancreas - Insulin and glucagon Thymus - T-cells,

More information

PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI

PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI 275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME

More information

! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002

! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 ! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER

More information

Male Patient Questionnaire & History

Male Patient Questionnaire & History Male Patient Questionnaire & History Name: Today s Date: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: E- Mail Address: May we contact you via E- Mail? ( ) YES

More information

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:

More information

Orthopedic Initial Questionnaire

Orthopedic Initial Questionnaire Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

Welcome to Tri-State Rehab Services

Welcome to Tri-State Rehab Services Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely

More information

PATIENT DEMOGRAPHICS. Mailing Address: Apt: City: State: Zip Code:

PATIENT DEMOGRAPHICS. Mailing Address: Apt: City: State: Zip Code: + ReenaMD NEW PATIENT FORM PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing):

More information

HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)

HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy) HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register

More information

MEDICAL HISTORY AND SCREENING FORM

MEDICAL HISTORY AND SCREENING FORM MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems

More information

PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM

PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If

More information

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your

More information

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -

More information

Welcome to Back Country Physical Therapy, Intake Form

Welcome to Back Country Physical Therapy, Intake Form Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):

More information

HORMONE REPLACEMENT THERAPY QUESTIONNAIRE

HORMONE REPLACEMENT THERAPY QUESTIONNAIRE HORMONE REPLACEMENT THERAPY QUESTIONNAIRE Name: Birth date: / Age: Address: Email Address: Home Phone: Work Phone: Cell Phone: Occupation: Emergency contact: o Phone number: o Relationship Ethnicity/Race:

More information

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340 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

More information

PEDIATRIC MEDICAL HISTORY FORM

PEDIATRIC MEDICAL HISTORY FORM Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other

More information

menopause and menopause treatments

menopause and menopause treatments menopause and menopause treatments what is menopause? Menopause is the time in a woman s life when her period stops. It is a normal change in a woman s body. A woman has reached menopause when she has

More information

X Guarantor/Parent/Guardian Signature

X Guarantor/Parent/Guardian Signature Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION (mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

More information

Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip

Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:

More information

(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _

(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _ 2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or

More information

Holistic Medicine Questionnaire

Holistic Medicine Questionnaire Holistic Medicine Questionnaire Cancellation Policy Because we schedule 1 hour and 15 minutes for your new patient appointment, we ask that you call us at least 48 hours in advance should you need to cancel

More information

New Patient Packet Address Social Security Number D.O.B. Patient's Last Name Patient's First Name Middle Initial Age:

New Patient Packet  Address Social Security Number D.O.B. Patient's Last Name Patient's First Name Middle Initial Age: Date New Patient Packet E-mail Address Social Security Number D.O.B Patient's Last Name Patient's First Name Middle Initial Age: Home Phone: Cell Phone: Work Phone: Address Male/Female: Single/Married/Divorced/Widowed

More information

WELCOME PATIENT CONDITION

WELCOME PATIENT CONDITION NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER

More information

LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH

LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS:

More information

Surviving and Thriving through Menopause. by Obstetrician/Gynecologist Leigh Bauer, D.O. Cuyuna Regional Medical Center

Surviving and Thriving through Menopause. by Obstetrician/Gynecologist Leigh Bauer, D.O. Cuyuna Regional Medical Center Surviving and Thriving through Menopause by Obstetrician/Gynecologist Leigh Bauer, D.O. Cuyuna Regional Medical Center As women enter their 40s and 50s there are a number of changes going on within their

More information

Patient Intake Form. Patient Information. How did you find out about our office?

Patient Intake Form. Patient Information. How did you find out about our office? Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our

More information

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient

More information

ADULT, CHILD & FAMILY COUNSELING

ADULT, CHILD & FAMILY COUNSELING ADULT, CHILD & FAMILY Sliding Scale Fee Schedule (circle the appropriate fee for you) Combined Gross Family Income Therapy Fee Per Session* $10,000 & Below $30 10,001 15,000 $35 15,001 20,000 $40 20,001

More information

MVA Accident Questionnaire

MVA Accident Questionnaire MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK

More information

Personal Injury Intake Form

Personal Injury Intake Form Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of

More information

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp

More information

Date. Initial. Initial. Minor ADDRESS. Cash ADDRESS

Date. Initial. Initial. Minor ADDRESS. Cash ADDRESS PATIENT NAME IF CHILD: PARENT'S NAME HOW DO YOU WISH TO BE ADDRESSED Single Married RESIDENCE - STREET Separated Divorced Widowed CITY STATE ZIP TELEPHONE: RES. EMAIL ADDRESS PATIENT/PARENT EMPLOYED BY

More information

Welcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.

Welcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know. Welcome! We want to thank you for allowing us the opportunity to provide you with the highest level of quality rehabilitation services possible. We are committed to providing you with a comfortable, friendly

More information

Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834

Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834 Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834 Dear New Patient: Welcome to Associates in Pediatric and Adult Urology, PA, a

More information

Orthopedic Initial Questionnaire. Date: Weight:

Orthopedic Initial Questionnaire. Date: Weight: Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)

More information

460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca

460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M

More information

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

PELED PLASTIC SURGERY HEADACHE HISTORY FORM HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:

More information

Physical Therapy Services Medical History Form

Physical Therapy Services Medical History Form Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently

More information

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( ) Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail

More information

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice? Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:

More information

Neuroendocrine Evaluation

Neuroendocrine Evaluation Neuroendocrine Evaluation When women have health concerns they usually prefer to discuss them with another woman. Dr. Vliet is a national expert on hormone-related problems and specializes in neuroendocrine

More information

FAMILY CONTACT INFORMATION

FAMILY CONTACT INFORMATION FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please

More information

New Patient Registration Information

New Patient Registration Information New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)

More information

Patient Information: In Case of Emergency: Physician: Insurance:

Patient Information: In Case of Emergency: Physician: Insurance: For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:

More information

INSURANCE VERIFICATION FORM - Atco Medical Associates

INSURANCE VERIFICATION FORM - Atco Medical Associates INSURANCE VERIFICATION FORM - Atco Medical Associates Patient Name Date of Birth Social Security # Single Married Separated Widowed Home Phone Cell Phone # 1 Cell Phone # 2 E-Mail Address Spouse's Name

More information

Cancellation/No Show Policy

Cancellation/No Show Policy Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You

More information

William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C

William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C 275 Collier Road NW Suite 470 Atlanta, GA 30309 William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C www.atlantabreastcare.com Phone:

More information

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:

More information

COMPREHENSIVE WOMEN S CENTER

COMPREHENSIVE WOMEN S CENTER COMPREHENSIVE WOMEN S CENTER (L to R) Anna Bobba, MD, Susan Scanlon, MD, NCMP Kathryn M. Ray, MD, Mary S. Farhi, MD, MPH, NCMP We are very pleased that you have selected our practice. Our mission is to

More information

Name Date. 5. Your attending physician/ Reproductive Endocrinologist is: If so, what was it? If so, is there any male factors diagnosed?

Name Date. 5. Your attending physician/ Reproductive Endocrinologist is: If so, what was it? If so, is there any male factors diagnosed? Female Fertility Intake Form Name Date 1. What is the purpose of your visit today? Preparation for pregnancy without medical intervention Adjunct to assisted reproductive technology 2. Estimated date of

More information

RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION

RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION Today s date: / / EMAIL: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. SS#: - - Birth date: Sex: [ ]

More information