NEW PATIENT PACKET

Date of first visit:

Date of Birth:

Name:

SSN:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

Marital Status:

Single Married Divorced Widowed

Occupation:

Employer:

Employer Address:

Spouse’s Name (If applicable):

Spouse’s Date of Birth:

Spouse’s SSN:

Spouse’s Employer:

Work Phone:

Spouse’s Cell Number:

Email:

Referral Physician/Source:

Emergency Contact’s Name:

Emergency Contact’s Phone Number:

Primary Insurance

Company and Address:

City:

State:

Zip:

Phone:

Contact Person:

Group #:

Policy #:

Insured’s Name:

Insured’s Date of Birth:

Effective Date:

Do you have a deductible?

Yes No

If yes, what is it?

Have you met your deductible?

Yes No

Do you have a Co-pay?

Yes No

If yes, amount?

Secondary Insurance

Company and Address:

City:

State:

Zip:

Phone:

Contact Person:

Group #:

Policy#:

Insured’s Name:

Insured’s Date of Birth:

Effective Date:

Do you have a deductible?

Yes No

If yes, what is it?

Have you met your deductible?

Yes No

Do you have a co-pay?

Yes No

If yes, what amount?

Worker’s Compensation Insurance

Date of Accident:

Case Number:

Is this insurance in your name?

Yes No

Do you have a deductible?

Yes No

If yes, what amount?

Employer at Time of Accident:

Employer Address:

City:

State:

Zip:

Insurance Carrier:

Insurance Carrier Address:

Contact Person/Adjuster:

Phone:

PATIENT CONSENT AND RELEASE

(Please Read Carefully)

I understand and agree that insurance policies are an arrangement between my insurance carrier and myself. This office will prepare and file all claims on my behalf to my insurance company. I authorize payment to be paid directly to Spine & Neuro Pain Specialists, which will be credited to my account upon receipt for any services furnished me by the physician not paid in full at the time of treatment. I understand that my signature also authorizes the release of medical information necessary to pay the claim. This assignment of benefits will remain in effect until revoked by me in writing. A photocopy of this assignment is considered to be as valid as the original. I understand that all services rendered to me are charged directly to me and I am personally responsible for payment if my insurance company refuses to pay the claims in a timely manner. (45 days from initial filing shall be considered a timely manner). I hereby give permission for Dr. Aaron Shores to administer medical treatment.

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

Patient Signature:

Date:

Guardian Signature:

Date:

PATIENT FINANCIAL RESPONSIBILITY DISCLOSURE

(Please Read Carefully)

At the present time, [Enter Your Insurance Name below], is my insurance carrier.

I will inform Spine & Neuro Pain Specialists of any changes with the above insurance carrier immediately. As a participating provider, Spine & Neuro Pain Specialists has agreed to file a claim for services rendered.

I will be responsible to pay Spine & Neuro Pain Specialists for the following

Any co-payment as set by my insurance carrier
Any unsatisfied deductible
Any amount my insurance carrier deems my responsibility
Any amount considered non-covered by my insurance carrier
Termination of coverage

I certify that I am not enrolled in any Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) that is not contracted with Spine & Neuro Pain Specialists. I assume full responsibility for all physician charges should the above criteria be met. I further agree that I will be responsible for all collection costs, including legal fees and court costs should this matter be referred to an attorney or collection agency.

I HAVE READ THE ABOVE INFORMATION AND AGREE TO BE FINANCIALLY RESPONSIBLE FOR SERVICES RENDERED BY SPINE & NEURO PAIN SPECIALISTS

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

Patient Signature:

Date:

Guardian Signature:

Date:

Spine & Neuro pain Specialists New Patient Questionnaire

(Please Complete ALL Sections)

Name:

Date:

Age:

Sex:

Male Female

Date of Birth

Referring Physician or Provider:

Primary Care Provider:

I. Chief Complaint:

II. History of Present Illness (HPI):

1) Do you experience pain?

Yes No

2) Do you experience numbess or tingling?

Yes No

If yes, where?

3) Do you have cramps in your arms or legs?

Yes No

If yes, where?

4) Date when the symptoms FIRST began:

5) If this is a flare of a chronic problem, what date did the most recent flare begin?

6) How did the pain begin? (Please check all that apply)

Accident at work

Incident at home

Motor vehicle accident

Following Surgery

Following Illness

Fall

Lifting injury

Just happened

Please describe what happened:

7) Initial Symptoms:

8) Have the symptoms changed since they began?

Yes No

If yes, how have they changed?

Worsened Unchanged

(Please describe)

9) Have you had any physical therapy since the accident?

Yes No

If yes, who?

Are you still going to physical therapy?

Yes No

II A. Motor Vehicle Accidents ONLY: (Only if the claim is active and open) (If not, proceed to section IIB)

1. Were you the driver or passenger?

Driver Passenger

2. Did you hit your head?

Yes No

Did airbags deploy?

Yes No

3. Did you loss consciousness (pass out)?

Yes No

Wearing seatbelt?

Yes No

4. Do you own the vehicle involved in the accident?

Yes No

If no, who does?

5. Did you go to emergency room (ER)?

Yes No

a) If yes, which emergency room?

b) If yes, did you go immediately from the accident scene?

Yes No

c). Did you go to the emergency room by ambulance?

Yes No

d) If you went to the emergency room, but NOT immediately from the accident scene, how long did you wait before going?

e) Did you drive yourself or did someone else take you? [] Self [] Someone else If someone else, who was it?

f) What treatment did you receive at the emergency room? (Please describe)

g) Where you sent home with any medications? [] Yes [] No If yes, what? (Please include name, dose, # of pills and frequency)

6. Did the pain start immediately after the accident?

Yes No

If no, how long after?

7. Did you have any pain problems before the accident?

Yes No

a) If yes, please describe:

b) If yes, is the pain worse since the accident?

Yes No

c) If worse, does the pain feel like the same kind of pain, just more intense, or is this a completely new type of pain for you?

Same just more intense New

d) If new, how is it different from your typical/baseline pain? (Please describe)

8. Have you seen any other doctors since the accident?

Yes No

If yes, who?

9. Have you had any physical therapy since the accident?

Yes No

If yes, who?

Are you still going to physical therapy?

Yes No

10. Have you had surgery because of an injury sustained in the accident?

Yes No

If yes: What kind of surgery?

Name of surgeon:

Add more

II.C. Has your pain changed with treatment?

Yes No

1) If yes, how?

Improved Worsened

2) If improved, what helped? If worse, what do you feel made you worse? (Please Describe) :

II.D. Have you had any injuries or accidents before, or since, this pain began that may have had an effect on your current condition?

Yes No

(Please describe)

II.E. What do you think is causing your pain?

II.F. Have you been to the emergency room for the treatment of your pain?

Yes No

If yes, which one(s) and how often?

II.G. Have you ever had any nerve blocks, or injections, for your pain? Examples include trigger point injections, epidural steroid injections, or facet injections

Yes No

1) If yes, when?

2) If yes, what type(s)?

3) If yes, what part of the body was injected? (please be specific: neck, low back, right shoulder, etc.)

4). Approximately how long did the injection(s) provide relief, if any? (Please be specific to each type of injection, if you have had more than one. Example: Low back epidural lasted 6 months).

II.I. Which of the following tests have you had to evaluate your pain? Please check ALL that apply

MRI:

Body part:

Date:

Facility:

CAT Scan:

Body part:

Date:

Facility:

X-ray(s):

Body part:

Date:

Facility:

Myelogram:

Date:

Facility:

Nuclear Bone Scan:

Date:

Facility:

DEXA Scan:

Date:

Facility:

Triple Phase Bone Scan:

Body part:

Date:

Facility:

Discogram:

Cervical Thoracic Lumbar

Date:

Facility:

Electrodiagnostic studies

(EMG/NCV):

Body part:

Date:

Facility:

Blood work:

Date:

Facility:

Sleep Study:

Date:

Facility:

Are you prescribed CPAP/BiPAP/Nocturnal Oxygen?

Yes No

If yes, which one(s):

Do you wear it every night?

Yes No

II. J. Pain Description:

Add more

2. What time of the day is your pain the worst?

Morning Mid-day Evening Bedtime

Other:

3. Does the pain interrupt your sleep?

Yes No

4. What does you pain feel like to you? (Please check all that apply)

Aching

Sharp

Dull

Stabbing

Burning

Intermittent

Pressure

Pins and Needles

Shooting

5. Where is the pain located?

6. If you experience pain in more than one location, is there ONE area that hurts more than any other right now?

Yes No

If yes, where?

7. What is the most comfortable position for you?

Sitting

Lying on your right side

Lying on your left side

Lying on your either side

Lying on your stomach

No position eases my pain

Other:

8. Is there any position that makes your pain better?

9. Is there ONE SINGLE thing that makes your pain worse than any thing else?

Yes No

If yes, which one:

Sitting

Standing

Walking

Sneezing/Coughing

Cold

Touch

Sex

10. Does your pain go to any other parts of the body?

11. Please rate your pain according to the scale below.
Using a zero to ten (0 to 10) Scale (Visual Analog Scale):

0: No Pain
1-2: Minimal Pain
2-4: Mild Pain (Discomforting)
4-6: Moderate Pain (Distressing)
6-8: Moderate to Severe
9: Severe, (Horrible Pain)
10: Worst Pain Possibly Imaginable (Excruciating Pain)

III. REVIEW OF SYSTEMS:

Height:

Weight:

IV. PAST MEDICAL HISTORY:

Where?

Cancer:

Chemotherapy or Radiation?

Yes No

Treating doctor?

Other:

2. (If applicable)

a) Is there a chance you might be pregnant?

Yes No

b) When was your last menstrual period?

Add new row

VI. FAMILY HISTORY:

Mother:

Living Deceased

Medical Problems

Father:

Living Deceased

Medical Problems

Children:

Living Deceased

Medical Problems

Siblings:

Yes No

If yes, who and why?

3. What was the highest grade/degree completed in school?

4. Marital Status:

Single Married Separated Widowed Divorced

5. Who do you live with currently?

6. Does anyone you live currently take pain medication(s)?

Yes No

If so, who and what type of pain medicine does he/she take?

7. Does anyone in your immediate family have chronic pain problems?

Yes No

If yes, who?

8. Are you currently employed?

Yes No

a) If yes, place of employment:

b) How long have you worked for the company?

c) If yes, are you

Part Time Full Time

# of hours per day?

a) Please describe the type of work you do.

b) If no, why are you not working?

Medical Leave Retired Laid off Personal Choice Disabled Reason

If you choose Disabled Reason, Please specify:

c) Did you return to work after the injury/onset of pain, at anytime?

Yes No

d) When did you last work at your usual job?

9. Do you plan to file for financial assistance?

Yes No

If yes, what type? (Please check all that apply)

Social Security

Worker’s Compensation

Social Security Disability

Medicare

Medicaid

Other

If Other, Please specify

10. If you are represented by an attorney, please complete the follow:

Attorney’s Name:

Address:

Phone Number (with area code):

IX. MEDICATION(S): (Please include name, dosage, frequency it is prescribed, and how often you take it)

Add more

X. ALLERGIES:

1. Are you allergic to any medications?

Yes No

If yes, which ones and what reaction did you experience?

2. Are you allergic to skin tapes?

Yes No

If yes, what type?

3. Are you allergic to soaps?

Yes No

If yes, what type?

4. Are you allergic to latex?

Yes No

IMPORTANT MEDICAL RECORD INFORMATION

In order to maintain the privacy of your protected health information, Spine & Neuro Pain Specialists will NOT release any records that were not generated by our office. If you supply our office with records from another provider, please ensure that you keep a copy for yourself. Once these records become the property of Spine & Neuro Pain Specialists, we will not be able to provide you with a copy of those particular records. If you should require copies of any records other than those initiated by Spine & Neuro Pain Specialists, please contact your other medical providers directly.

AUTHORIZATION FORM TO SHARE PROTECTED HEALTH INFORMATION

Purpose

To permit Spine & Neuro Pain Specialists to respond to patient inquiries regarding Protected Health Information. To authorize Spine & Neuro Pain Specialists to release medical, psychiatric, alcohol, HIV results, and/or drug abuse information contained in the patient’s medical records.

By initialing this paragraph, I consent to and understand that this authorization allows the disclosure of my medical records, including psychiatric, alcohol, HIV results, and/or drug abuse information contained in my chart to the individuals identified this authorization.

Patient Rights Related to this Authorization & Right to Revoke this Authorization

I understand that I do not have to sign this authorization in order to receive treatment from this practice. I am aware that I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, I understand that my medical records may be subject to re-disclosure by the recipient and may no longer be protected. I am also aware that I have the right to ask for my own medical records and to receive those records in a digital or paper format. I understand that my Protected Health Information may be shared with the people listed below and that they may not be required to comply with federal health information privacy laws, and that they may use and further disclose any of my Protected Health Information they receive.

I understand that I may cancel my authorization in writing at any time by giving written notice to Spine & Neuro Pain Specialists’ privacy officer. My written notification must be submitted to the practice’s privacy officer at: 2103 Jenks Avenue, Panama City, FL 32405. I further understand that cancellation of my authorization will not affect any action taken by Spine & Neuro Pain Specialists prior to receiving my written notice of cancellation.

Section 1

Patient whose Protected Health Information is to be disclosed:

Name:

Date of Birth:

Section 2

Identify the person(s) with whom your information may be shared and their relationship to you.
** (According to privacy law regulations, this release of information must be on file for even the most basic information, such as confirming appointment times. If a person is not listed, we cannot even leave a message with him/ her regarding you as our patient.)

Add more

Section 3

This authorization shall remain in effect until (expiration or event):

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

Patient Signature:

Date:

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

Witness Signature:

Date:

If someone else is signing this authorization form on behalf of the patient, please provide the following information:

Representative Signature:

Date:

Relationship to Patient:

Date:

Indicate if records are requested at this time:

Yes No

If yes:

Electronic copy Paper copy (Please inquire at front desk as to cost associated with electronic or paper copy of patient records)

IMPORTANT MEDICAL RECORD INFORMATION

AUTHORIZATION FORM TO SHARE PROTECTED HEALTH INFORMATION WITH OTHER MEDICAL PROVIDERS

Purpose

To permit Spine & Neuro Pain Specialists to respond to patient inquiries regarding Protected Health Information. To authorize Spine & Neuro Pain Specialists to release medical, psychiatric, alcohol and/or drug abuse information contained in the patient’s medical records for the purpose of treatment.

Patient Rights Related to this Authorization & Right to Revoke this Authorization

I understand that I do not have to sign this authorization in order to receive treatment from this practice. I am aware that I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, I understand that my medical records may be subject to re-disclosure by the recipient and may no longer be protected. I am also aware that I have the right to ask for my own medical records and to receive those records in a digital or paper format.

I understand that I may cancel my authorization in writing at any time by giving written notice to Spine & Neuro Pain Specialists’ privacy officer. My written notification must be submitted to the practice’s privacy officer at: 2103 Jenks Avenue, Panama City, FL 32405. I further understand that cancellation of my authorization will not affect any action taken by Spine & Neuro Pain Specialists prior to receiving my written notice of cancellation.

Section 1

Patient whose Protected Health Information is to be disclosed:

Name:

Date of Birth:

Section 2

Identify the medical providers with whom your information may be shared.

Add another provider

Section 3

This authorization shall remain in effect until (expiration or event):

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

Patient Signature:

Date:

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

Witness Signature:

Date:

If someone else is signing this authorization form on behalf of the patient, please provide the following information:

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

Representative Signature:

Relationship to Patient:

Date:

ARBITRATION AGREEMENT BETWEEN DOCTOR AND PATIENT

(Please read carefully)

This agreement is made between Dream Medical LLC dba Spine & Neuro Pain Specialists, and Aaron Shores, M.D. and his physician extenders, agents, employees, or any of the foregoing referred to hereinafter as “doctors” and [Enter Patient Name Below] hereinafter referred to as “patient”

It is the intention of the parties to this agreement to bind not only themselves, but also their heirs, personal representatives, guardians, or any other persons deriving their claims through, and on behalf of, the patient.

It is understood by the patient that he or she has voluntarily selected and he or she is neither required to use Dream Medical LLC dba Spine & Neuro Pain Specialists, nor any of the doctors involved in their treatment and that there are other competent pain management physicians in Florida who may act as the patient’s treating physician.

It is further understood that in the event of any controversy or dispute which might arise between the doctor and the patient, regardless of whether the dispute concerns the medical care rendered, or payment of surgical or other fees, or any other matter whatsoever, then the parties agree that the dispute shall be resolved by arbitration as provided by the Florida Arbitration Code, Chapter 682, Florida Statues. In addition, each party shall be entitled to the right, protections and defendants of Chapter 766, Florida Statutes.

Disputes and Consideration

In the unfortunate event of any claim for medical malpractice or otherwise, and in consideration for this agreement, the parties would like to (a) keep things as simple as possible; (b) enhance early resolution of their differences; (c) avoid lengthy drawn out litigation through the courts; (d) avoid the stress associated with traditional litigation and jury trials; and (e) minimize all costs, expenses and attorney’s fees.

This arbitration shall be binding and shall be in lieu of, and instead of, any trial by judge or jury. Each party shall choose one arbitrator and the two arbitrators shall choose a third arbitrator.

Each party shall be entitled to the discovery available for under the Florida Rules of Civil Procedure. The panel of three (3) arbitrators shall hear and decide the controversy, and the decision shall be binding on all parties, and may be enforced by a court of competent jurisdiction.

Duty to Defend and Indemnify

For each individual or entity with a claim that is not bound by this agreement (“nonparty”), it is the parties’ intent that they shall adopt and comply with this agreement 100% so that the parties can avoid piecemeal litigation and ensure consistency, closure, and finality in one forum. For each non-party claim against the patient’s physician brought outside this agreement, you shall (a) defend and (b) indemnify the patient’s physician against said claim(s).

If any provision of this Agreement shall be held invalid under any applicable laws, such invalidity shall not affect any other provision of this Agreement that can be given effect without the invalid provision. Further, all terms and conditions of this Agreement shall be deemed enforceable to the fullest extent permissible under applicable law, and, when necessary, the court is requested to reform any and all terms or conditions to give them such effect.

I understand that by signing this agreement I am waving my right to a jury trial, and instead, have agreed to participate in arbitration.

This agreement shall remain in effect for all treatment and surgery provided to the patient, presently and at any future date. By signing below, I am indicating that I have read and agree to the foregoing terms.

In witness whereof, we have set our hands this date:

PATIENT:

By:

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

By:

Patient’s Spouse if available

Consent to Receive Text Message Appointment Reminders

By signing below, I authorize Dream Medical d/b/a Spine and Neuro Pain Specialists to contact me by SMS text message for appointment reminders. I understand that message/data rates may apply to messages sent by Dream Medical d/b/a Spine and Neuro Pain Specialists under my cell phone plan.

I understand that text messaging is not a secure format of communication. There is some risk that individually identifiable health information or other sensitive or confidential information contained in such text may be misdirected, disclosed to or intercepted by unauthorized third parties. Information included in text messages may include your first name, date/time of appointments, name of physician, and physician phone number, or other pertinent information.

By signing below, I indicate I am the primary user for the mobile phone number listed and I accept the risk explained above and consent to receive text messages via automated technology from Dream Medical d/b/a Spine and Neuro Pain Specialists to the phone number that I have provided.

Patient Name

My text/mobile phone number is

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

Signature

Date

Your information will be encrypted.