New Patient Information

Patient's Name

Date

Email address

SS No. / SIN No.

Date Of Birth

Home Phone No.

Cell Phone

Work Phone No.

Check appropriate Box

Minor Single Married Divorced Widowed Separated

Patient’s Address

City

State

Zip

Employer Name

Spouse or guardian’s name

Spouse’s Employer

Whom may we thank for referring you?

Person to contact in case of an emergency

Work Phone No.

In case of a medical emergency, if the patient is of school age 15+, is ok to treat in my absence

Parent or Guardian

Date

Responsible Party

Name of the person responsible for this account

Relationship to patient

Address

Home Phone No.

Email address

Cell Phone No.

Driver’s License No.

Date of Birth

Do you have any Medical Insurance? if yes, complete the following below

Yes No

Name of the insured

Relationship to Patient

Birthdate

SSN / SIN / No.

Name of Employer

Work Phone No.

Address of Employer

State

Zip

Insurance Company

Group No.

ID No.

Ins. Co Address

City

State

Zip

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay Scott Wagner Integrated Medicine, PLLC as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/ healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms, or treatment information contained in your records that are needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/ insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or an administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, tests, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan of this document is to be considered as valid and as enforceable as the original.

Sign this

Day of

Year

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name / Signature or Guardian if applicable

Date

Health History

Chief Complaint

History of Present illness

Mark the areas on the image where you are experiencing symptoms

Timing

What other areas of your body are affected by this problem?

Are you on any medications now for this problem?

Yes No

What have you tried in the past to handle your problem?:

(Heat ice over the counter medications prescription medications rest exercise physical therapy chiropractic adjustments massage)

Duration

(How long have you had this pain/ problem? When did it start?)

What activities have you given up or changed due to this Problem?

(Example: stopped climbing steps as often)

What activities increase symptoms/makes problems worse?

(What makes the pain/problem worse or better? Going up and down stairs, brushing hair, etc)

Past Medical History

(Have you ever had the following: (circle “yes” or “no”/ leave blank if you are uncertain.)

Measles

Yes No

Anemia

Yes No

Back Trouble

Yes No

Hepatitis

Yes No

Mumps

Yes No

Bladder Infection

Yes No

High Blood Pressure

Yes No

Ulcer

Yes No

Chicken Pox

Yes No

Epilepsy

Yes No

Low Blood Pressure

Yes No

Kidney Disease

Yes No

Whooping Cough

Yes No

Migraine Headaches

Yes No

Hemorrhoids

Yes No

Thyroid Disease

Yes No

Scarlet Fever

Yes No

Tuberculosis

Yes No

Date of last Chest X-Ray

Bleeding Tendency

Yes No

Diphtheria

Yes No

Diabetes

Yes No

Asthma

Yes No

Small pox

Yes No

Cancer

Yes No

Hives or Eczema

Yes No

Pneumonia

Yes No

Polio

Yes No

AIDS & HIV

Yes No

Rheumatic Fever

Yes No

Glaucoma

Yes No

Infections Mono

Yes No

Arthritis

Yes No

Hernia

Yes No

Bronchitis

Yes No

Bronchitis

Yes No

Venereal Disease

Yes No

Blood or Plasma Transfusion

Yes No

Mitral Valve Prolapse

Yes No

Stroke

Yes No

Any other disease?

Yes No

If yes, please specify

Previous Hospitalizations/Surgeries/Serious Illnesses

When?

Hospital, City, State

Medication: (include non-prescription)

Primary Care Physician

Have you ever taken Fen-Phen/Redux?

Yes No

Are you taking any medications (prescription or over the counter) for acid indigestion?

Yes No

If yes, what type?

Do you have a sulfa allergy?

Yes No

Allergies/Medication Allergies

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Clinical Signature

Date Reviewed

Patient Social History

Marital Status

Single

Married

Separated

Divorced

Widowed

Use of Alcohol

Never

Rarely

Moderate

Daily

Use of Tobacco

Never

Rarely

Moderate

Daily

If yes, type of frequency

Excessive Exposure At home or at work to

Fumes

Dust

Solvents

Airborne Particles

Noise

Family Medical History

Add Additional Member

Indicate which of the below you have experienced in the last 1-2 months

1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly

Add new row

Do you have a living will? ? (DO NOT RESUSCITATE)

Yes No

IF YES PLEASE PROVIDE/ATTACH A COPY OF YOUR FILE.

Add file

Please upload a file

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of the Patient, Parent or Guardian

Date

Signature of person holding POA for patient

Date

Doctor’s Review

Signature of Doctor

Date

Provider Statement of Patient/Client Rights and Responsibilities

Patients/Clients have the right to be treated with dignity and respect.
Patients/Clients have the right to fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment for care.
Patients/Clients have the right to have their treatment and other patient information kept private. Only by law may records be released without patient permission.
Patients/Clients have the right to access care easily and in a timely fashion.
Patients/Clients have the right to a candid discussion about all their treatment choices, regardless of cost or coverage by their benefit plan.
Patients/Clients have the right to share in developing their plan of care.
Patients/Clients have the right to the delivery of services in a culturally competent manner.
Patients/Clients have the right to information about the organization, its providers, services, and role in the treatment process.
Patients/Clients have the right to information about provider work history and training.
Patients/Clients have the right to information about clinical guidelines used in providing and managing their care.
Patients/Clients have a right to know about advocacy and community groups and prevention services.
Patients/Clients have a right to freely file a complaint, grievance, or appeal, and to learn how to do so.
Patients/Clients have the right to know about laws that relate to their rights and responsibilities.
Patients/Clients have the right to know of their rights and responsibilities in the treatment process and to make recommendations regarding the organization’s rights and responsibilities policy.
Patients/Clients have the responsibility to treat those giving them care with dignity and respect.
Patients/Clients have the responsibility to give providers the information they need, in order to provide the best possible care.
Patients/Clients have the responsibility to ask their providers questions about their care.
Patients/Clients have the responsibility to help develop and follow the agreed-upon treatment plans for their care, including the agreed-upon medication plan.
Patients/Clients have the responsibility to let their providers know when the treatment plan no longer works for them.
Patients/Clients have the responsibility to tell their providers about medication changes, including medications given to them by others.
Patients/Clients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits.
Patients/Clients have the responsibility to let their providers know about their insurance coverage and any changes to it.
Patients/Clients have the responsibility to let their providers know about problems with paying fees.
Patients/Clients have the responsibility not to take actions that could harm others.
Patients/Clients have the responsibility to report fraud and abuse.
Patients/Clients have the responsibility to openly report concerns about the quality of care.
Patients/Clients have the responsibility to let their providers know about any changes to their contact information (name, address, phone, etc).
Patients/Clients have the right and the responsibility to understand and help develop plans and goals to improve their health.
I have read and understood my rights and responsibilities.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Your information will be encrypted.