New Patient Intake Form

Prescription Medications

Past Medical History

Please List All Prior Surgeries:

FAMILY HISTORY

SOCIAL HISTORY

Review Of Symptoms: Do You Have These Symptoms?

CURRENT PROBLEM

PATIENT FINANCIAL POLICY

Due To The Complicated Nature Of Health Insurance, Your Understanding Of Our Financial Policies Is Essential To Your Care And Treatment. If You Have Any Questions, Please Do Not Hesitate To Ask Our Front Office Staff.

• As Our Patient, You Are Responsible For All Authorizations/Referrals Needed To Seek Treatment In This Office.
• Unless Other Arrangements Have Been Made In Advance By You, Payment For Office Services Are Due At The Time Of Service. We Accept Cash, Check, Visa, And Mastercard.
• Your Insurance Policy Is A Contract Between You And Your Insurance Company. As A Courtesy, We Will File Your Insurance Claim For You If You Assign The Benefits To The Doctor. In Other Words, You Agree To Have Your Insurance Pay The Doctor Directly.
• We Have Made Prior Arrangements With Most Insurers To Accept An Assignment Of Benefits. We Will Bill Those Plans With Which We Have An Agreement And Will Only Require You To Pay The Co-Pay/Co-Insurance/Deductible At The Time Of Service.
• All Health Plans Are Not The Same And Do Not Cover The Same Services. In The Event Your Health Plan Determines A Service To Be ‘Not Vovered,’ Or You Do Not Have Authorization, You Will Be Responsible For The Complete Charge. You Are Responsible For Charges To Any Services Rendered. Patients Are Encouraged To Contact Their Plans For Clarification Of Benefits Prior To Services Rendered If They Have Any Doubt Of Coverage.
• You Must Inform The Office Of All Insurance Changes And Authorization Referral Requirements. In The Event The Office Is Not Informed, You Will Be Responsible For Any Charges Denied.
• A Custom Brace Or Custom Orthotic Are Not Refundable. You May Not Return A Custom Brace Or Custom Orthotic For Any Reason. You Understand That You Are Responsible For Charges Not Covered By Your Insurance For Custom Braces Or Orthotics.
• Past Due Accounts Are Subject To Collection Proceedings. All Fees Including, But Not Limited To Collection Fees, Attorney Fees, And Court Fees Shall Become Your Responsibility In Addition To The Balance Due This Office.
• There Is A Service Charge Of $25.00 For All Returned Checks. Your Insurance Company Does Not Cover This Fee.
• There Is A $20 Fee For Appointments Missed Without 24 Hour Notification.
• Occasionally You May Have A Form (DMV, Disability, Insurance, etc) For The Doctor To Complete. Depending On The Complexity Of The Form, If You Choose To Have It Completed By our office there is a $15 charge.
• If You Need Copies Of Your Records For Any Reason, There Will Be A $15 Fee For This Service. Prices May Vary Depending On The Amount Of Paperwork To Be Copied.

To The Best Of My Knowledge, I Have Answered The Questions On This Form Accurately. I Understand That Providing Incorrect Information Can Be Dangerous To My Health. I Understand That It Is My Responsibility To Inform The Doctor And Office Staff Of Any Changes In My Medical Status.

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.