If Medicare is Secondary Insurance, one must of the following be selected:
Please list any persons below can obtain any/all medical information on myself/patient and whom we can communicate with about your medical information .This is in accordance with the Knight Neurology LLC notice of privacy practices policy. (This is optional but even immediate family members such as a spouse must be specifically listed to obtain any medical information about you.)
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Any other doctors (and their addresses) to whom reports should be sent:
Preferred Pharmacy Name (leave blank if unknown):
Please list current medications including vitamins and other non-prescription medications:
Pleaselist all medicationsthat have caused you to have an allergic reaction.
Past Medical History:
Do you have or have you had any of the following:
Please include all primary blood relatives(parents, siblings, children) even if they are healthy.
Illicit Drug Usage:
Your information will be encrypted.