New Patient Forms

CONSENT TO RECEIVE THE APPOINTMENT REMINDERS THROUGH MOBILE PHONE TEXT MESSAGING

Last Name

Middle Name

First Name

Birth Date

Mobile Phone Number

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's Signature

Date

Patient Information

Name

Date of Birth

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Ethnicity

Primary Language

Employer

Occupation

Spouse's Name

Emergency Contact

Pharmacy Used

Insured Information

Insured Name

Date of Birth

Address

Home Phone

City

State

Zip

Relationship

Insurance Information

Primary Insurance

Identification #

Group #

Secondary Insurance

Identification #

Group #

No fault

Claim #

Adjuster

Address

Phone

Referring or Primary Doctor

I authorize Dr. Velickovic to furnish my insurance carrier with all information to process my claim for services rendered. In regard to medicare, I understand that reimbursement for some services, tests, etc. deemed necessary by my physician and explained to me, may not be covered under medicare and denied for payment, I will be responsible for such charges.

In regard to managed care/referral plans, I understand that it is my responsibility to request referral from my primary care doctor in advance and to be aware of the amount of allowable visits per referral.

I hereby assign, transfer, and set over to Dr. Velickovic sufficient monies and/or benefits to which I may be entitled to from governmental agencies, insurance carriers, and others who are financially liable for my medical care to cover costs of the care rendered to myself and my dependents.

I have read and agree and to the above information.

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 Patient or Responsible Party

Date

Can the office of Dr. Velickovic contact you for appointment reminders or other health-related benefits and services that may be of interest to you?

Yes No

Can the office of Dr. Velickovic leave a medically related message on your answering machine?

Yes No

Can the office of Dr. Velickovic disclose PHI (Private Health Information) to a family member or a friend?

Yes No

If yes, please provide us with names and Date of Birth.

Add new row

If you suffer from seizure, convulsive disorder, epilepsy, fainting or dizzy spells, or any condition which causes unconsciousness, NYS law requires that you do not drive for 1 year after the last event.

Signature of Patient

Date

Acknowledgement

I hereby acknowledge the receipt of the notice of privacy practices.

Signature

Print Name

Date

Name

Address

Telephone Number

To facilitate your neurological evaluation, we would like you to answer the following questions and bring this letter with you at the time of your appointment. Please elaborate on any "YES" answers using the space provided if necessary.

Birth Date

Age

Sex

Place of Birth

Purpose of consultation

Are you followed by a general practitioner, internist or pediatrician?

Yes No

If so, please give name, address, and telephone.

Are you

Right-handed Left-handed

Present height

Present weight

1. Marital Status

Spouse Age

Spouse Health

2. Educational Level

3. Are you presently employed?

Yes No

Occupation

Present

Former

How many children do you have (list names, sex, and ages)?

Add new row

4. Who currently lives with you at home?

Do you have any pets (list)?

5. Smoking History: (If you never smoked, place 0 in all answers.)

Year stopped

Number of years smoked

Current number of packs/day

Maximum number of packs/day in the past

Drinking History: (If you never drank alcohol, place 0 in all answers.)

Current status:

The maximum drunk in past:

Number of beers/day

Glasses of wine/day

Ounces of hard alcohol/day

Have you in past or do you use any recreational drugs (when, what, and how much)?

1. What medicines are you taking now? Please list them and their doses. (Include nasal sprays and vitamins)

List the medicines you have taken in the past for your present illness.

Have you ever been exposed to any toxic substances?

Yes No

If yes, please provide details.

What other medications do you take on a regular basis (including over-the-counter drugs, vitamins, sleeping pills, antihistamines, cold remedies, and birth control pills)?

2. Have you ever been hospitalized? If so, when, where, and for what?

3. What other medical problems do you have?

Review of Systems

Do you have any of the following? Please use the space below to elaborate when pertinent.

Allergies?

Are you allergic to any medications?

Family History

1. Father's current age (if alive)

Or age of death

Cause of death

Any medical problems

Mother's current age (if alive)

Or age of death

Cause of death

Any medical problems

Do you have brothers or sisters? List ages, and health and death status.

Add new row

Please list health status of your children.

2. Is there any disease that tends to run in your family (e.g. diabetes, high blood pressure, nervous or mental disease or something like your present condition)?

If you suffer from seizure, convulsive disorder, epilepsy, fainting or dizzy spells, or any condition which causes unconsciousness, NYS law requires you that you do not drive for 1 year after the last event.

Patient Signature

Date

Physician's Statement: I have reviewed this document on this date.

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.

Physician Signature

Date

Your information will be encrypted.