New Patient Intake for Medical Treatment

Name *

First

Last

Date of Birth

Marital Status

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Employment

Occupation

Employer

Employer Address

Health Insurance Information

Primary Insurance

Insurance ID#

Group#

Secondary Insurance

Secondary Insurance ID#

Secondary Insurance Group#

Primary Care Name

Primary Care Phone

Chiropractor Name

Chiropractor Phone

Pharmacy

Pharmacy Address

Accident Related Questions

Is this related to:

Auto Accident
Work Accident
Fall or Other
Not Related to an Accident

Imaging Tests Done

X-Ray(s)
MRI(s)
CT Scan(s)
Other

Date of Injury or Accident

Please state the reason you are here today

Please list past surgeries

Please list all medications you are currently taking

Please list all allergies to drugs or food

Do you presently use or have used illicit drugs such as cocaine?

Do you drink alcohol?

Do you smoke?

Family Medical History

Personal Medical History

Other medical information you would like us to know?

Neck or Arm Pain

Do you have neck or arm pain?

Back or Leg Pain

Do you have back or leg pain?

Treatments You've Tried

Other

Do we have your permission to leave a message on the phone number(s) you have provided?

May we discuss your medical information with...(family, attorney, PCP, chiropractor)

If someone calls for you or comes in and asks for you while you are here, do we have permission to tell them you are here?

Whom may we discuss your medical records with (please list names)?

How did you hear about us?

Consent *

By checking, I agree to share my form responses with Allspine Laser and Surgery Center.

New Patient Application

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