PATIENT INFORMATION INSURANCE INFORMATION
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- Bertha Short
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1 PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER NAME PHONE WHOM MAY WE THANK FOR THE REFERRAL EMERGENCY CONTACT: NAME PHONE# RELATION INSURANCE INFORMATION NAME OF INSURED RELATION TO PATIENT DATE OF BIRTH INSURANCE COMPANY PHONE ADDRESS CITY ST ZIP MEMBER ID# GROUP NAME/# ADDITIONAL /SECONDARY INSURANCE INFORMATION (if applicable) NAME OF INSURED RELATION TO PATIENT DATE OF BIRTH INSURANCE COMPANY PHONE ADDRESS CITY ST ZIP MEMBER ID# GROUP NAME/# I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE. I AGREE TO NOTIFY EQUILIBRIUM IMMEDIATELY WHENEVER I HAVE CHANGES IN MY PERSONAL INFORMATION LISTED ABOVE, INCLUDING MY INSURANCE STATUS. INITIAL HERE
2 PLEASE MARK ALL SYMPTOM AREAS ON THE BODY DIAGRAM YOUR NAME: 913 SW 16 th Avenue DATE: BELOW (use the key provided): * Ache + Stabbing - Burning O Pins & Needles > Numbness Please rate your symptom intensity right now: (circle) When did your symptoms begin? Work-related? Y / N Motor Vehicle Collision? Y / N How did your pain begin? (circle) Bending Lifting Fall Other: Prior treatment for your symptoms? (circle) Chiropractic Acupuncture Massage PT Medical Date: Results: Diagnoses Given To You: Anti-inflammatories/Pain Meds? (circle) Ibuprofen Acetaminophen Other: Pain Chronology: (circle): Improved Worsened Constant Intermittent Other: Has this happened in the past? NO / YES (when? treatment? results? ) YOUR NAME: DATE: For Provider Use Only How do the following affect your pain? (circle) Cough/sneeze: worse better no difference Sitting: worse better no difference Sit to stand: worse better no difference Bending forward: worse better no difference Bending back: worse better no difference In the morning: worse better no difference Night time: worse better no difference Lifting: worse better no difference Standing: worse better no difference Walking: worse better no difference Lying face down: worse better no difference Looking down: worse better no difference Looking up: worse better no difference Turning head: worse better no difference
3 YOUR NAME: DATE: Are you (or have you ever been) under the care of a primary care physician in the last year? NO / YES (physician name, reason): YOUR NAME: DATE: Do you or any of your immediate family members have any of the following inheritable conditions? NO / YES (circle and indicate whom below) heart disease cancer diabetes strokes high blood pressure arthritis scoliosis other: If you are working, please circle all of the following items that pertain to your job or jobs: Full Time (>35 hrs/wk) Part Time (<35 hrs/week) Sitting Standing Heavy Lifting Air Travel Have you taken a leave from work because of your injuries? NO / YES (when? restrictions? ) If you are currently exercising, please circle any of the following items that pertain: Frequent (>5 times/week) Moderate (3-4 times/week) Infrequent (1-2 times/week) Aerobic Exercise (> 30 mins) Aerobic Exercise (<30 mins) Weight Lifting Yoga/Pilates Other: Do you currently smoke/drink alcohol/use recreational drugs? (circle) NO/YES (How much and how frequent? ) Please list any surgeries and/or hospitalizations you have had: Procedure: Year: Result: Procedure: Year: Result: Procedure: Year: Result: Please list any medications you are currently taking: Name: Dosage: Date started taking: Name: Dosage: Date started taking: Name: Dosage: Date started taking: Please circle any of the following symptoms/complaints you have experienced: fever night sweats unexplained weight loss changes in bowel/bladder function headaches change in vision change in hearing difficulty swallowing chest pain poor circulation cough difficulty breathing nausea vomiting bruise easily swollen/painful joints dizziness allergies depression anxiety difficulty sleeping skin rashes/irritation
4 INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by an Equilibrium chiropractic physician and/or other licensed doctors of chiropractic who now or in future will treat me while employed by, working for or associated with or serving as back-up for Dr. Bhalerao, including those working at the clinic or office listed herein or any other office or clinic. I understand that the doctor will conduct a full exam with a complete report of findings. I have had or will have an opportunity to discuss with the doctor and/or other office or clinic, the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to: fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course if the procedure which the doctor feels at the time, based upon facts then known, to be in my best interest. AUTHORIZATION FOR DIRECT PAYMENT OF INSURANCE BENEFITS TO THE HEALTHCARE PROVIDER AND CLINIC: I, or my representative, authorize direct payment to the provider(s) and/or clinic rendering services during this visit or any insurance benefits payable to me. AUTHORIZATION TO RELEASE INFORMATION: In obtaining payment for services, I authorize my healthcare provider and the clinic to furnish information form my medical records to any company that may be responsible for payment of all or part of my visit and provider charges, including my insurance companies and their representatives, and my employer or union if they are involved in the processing of the claim. If I have been referred by, or am being referred to another healthcare provider, I authorize the release of my clinical information to this provider for continuing care. PROTECTED DIAGNOSIS: If my medical record contains information about drug or alcohol diagnosis or treatment, or HIV testing, I specifically authorize the release of this information for billing purposes ONLY. Any other release of such information may only be released with another specific consent form.
5 I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE CONSENT. I HAVE ALSO HAD OR WILL HAVE AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW I AFREE TO THE CONDITIONS STATED ABOVE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF TREATMENT FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK TREATMENT. Patient name PLEASE PRINT DATE Patient signature PLEASE SIGN AUTHORIZATION TO TREAT MINOR If the patient is under the age of 18, or is otherwise unable to sign, please complete the following. Patient is years of age OR unable to sign because: Signature Date Relationship to patient
6 CANCELLATION POLICY Effective 02/02/15 Equilibrium requires a 24 hour advance cancellation for all appointments. If I am unable to give 24 hours advance notice the following fees will be charged; $76.50 for a chiropractic appointment, $75.00 for a massage appointment and $88.00 for an acupuncture treatment. I have read and understand the cancellation policy. Patient Signature Date
7 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that by signing below that I have received a copy of this office s Notice of Privacy Practices. Print Name Signature Date FOR OFFICE USE ONLY We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because: Communication barriers prohibited obtaining the acknowledgment An emergency situation prevented us from obtaining acknowledgment Other (Please Specify Below)
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:
Insurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
PERSONAL INFORMATION
Date: Bruns Chiropractic Clinic EXISTING PATIENT INTAKE FORM (For patients treated within the past 3 years) PERSONAL INFORMATION Name: First MI Last Preferred Name: Gender: M F DOB: / / Age Social Security
Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )
Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:
Function First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
Work Injury Information Continued
Welcomes You Full Name: Today s Date: DOB: M / F Social Security #: DL# Address: City: State: Zip Code: Home # : Cell #: Occupation: Employer: Employer Address: Employer Phone: Employer Fax: Emergency
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:
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
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
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
20. Please describe any pain or symptoms: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d.
Name Date of Birth Phone Address City State Zip Email: Employer s Name Employer s Address Your Ins. Co. Claim # Claims Adjustors Name Driver/Owner Have you retained an attorney? ( ) Yes ( ) No If yes attorney
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
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:
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
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:
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
BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(
MVA New Patient Paperwork
Please Complete Entire Form MVA New Patient Paperwork Patient Name: M F Today s Date / / Address: Employer: _ City, State, Zip: Address: Home Phone: ( ) City, State, Zip: Cell 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 # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
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Personal Injury Questionnaire
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Accident / Injury Report
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New Patient Registration Information Form 8026 5/09 3038 PR&C Dear WellSpan Orthopedics Patient: Welcome to WellSpan Orthopedics. Thank you for allowing us the opportunity to assist with your health care
WORKER S COMPENSATION HISTORY FORM NAME (Last, First, Middle Initial) Height Weight
341 Magnolia Avenue, Suite 101 28078 Baxter Road, Suite 330 Corona, CA 92879 Murrieta, CA 92563 (951) 735-6060 (951) 735-4510 Fax (951) 677-2157 www.ctoamg.com WORKER S COMPENSATION HISTORY FORM NAME (Last,
WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?
Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address
PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:
Patient Questionnaire Auto-Collision
Patient Questionnaire Auto-Collision Patient Name: (First) (Middle) (Last) (Suffix) Today's Date: / / Birth Date: / / Age: SSN: Gender: (circle) F M Height: ft in Weight: lbs (circle one) Right handed
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
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
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405
19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405 Welcome to our practice. We are happy that you selected us as your eye care provider and appreciate the opportunity
PERSONAL INJURY CASE HISTORY
Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH 43065 (614) 436-9070 (p) ~ (614) 436-8803 (f) PERSONAL INJURY CASE HISTORY 1. Circle the severity (0 = No Pain to 10 = Very Severe Pain)
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked
*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM
Oasis Chiropractic Injury/ Auto Accident/ Slip & Fall Form First Name: Last Name: Title: (check one) Mr. Mrs. Ms. Miss Dr. Other Patient ID#: Single Married Widowed Under 18 (Minor) Separated Divorced
Full Name: Gender M F Age: Birth Date: / / Social Security#: - - Driver s License #: Home Phone: ( ) Employer: Occupation: Work Phone: ( )
Personal Injury / Accident Medical History Intake Form Release Chiropractic and Wellness Center Please provide your Driver s License to our staff for your file. ABOUT YOU Full Name: Gender M F Age: Birth
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:
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:
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 # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
History Questionnaire
History Questionnaire Today s Date Physician Patient Information Patient s Name Is this your legal name? Street Address Mr. Miss. Marital Status (circle one) Mrs. Ms. Single Mar Div Sep Wid If not, what
*2PHT* REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE
*2PHT* 2PHT Page 1 REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE In order for us to fully address all aspects of your problem, the following information is needed. Please take time to complete this form.
Integrative Therapies
Hello! And welcome to Integrative Therapies! Integrative Therapies 7E Oak Branch Drive Greensboro, NC 27407 www.integrativetherapies.net 336-294- 0910 We are very happy that you have chosen to partner
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
Referrals It is your responsibility to bring your referral if required. Failure to do so may result in cancellation of your appointment.
Welcome to Capital Endocrinology! We are happy to have you as a patient in our practice. Please take note of the following policies. Following these policies will help in making your visit as efficient