Wellness Medical Center

If you have any questions or problems filling out this form please contact us at the number listed below.

Telephone: (617)282-8700

Please read the instructions so you may fill out this form correctly

1. Select the type of injury you experienced so this intake form can adjust accordingly.

2. Complete all relevant fields for your selected section.

3. Double-check everything to make sure no information is missing.

4. Submit the form once all required fields are filled out properly.

Date of Injury:

Section 1: Patient Information

First name

Last name

Phone number

Email address

Address

City

State

Zip Code

Date of birth

Age

Social Security #:

ID: Identification Card Please take a picture of your ID or Driver's License and attach it here!

Add file

Please upload a file

Section1.2 Employment Information

Are you employed?

Yes

Please fill out the information below.

Please skip to the next section.

Employers Name:

Employer's Telephone #:

Employers Address:

Section1.3 Health Insurance Information

Do you have Health Insurance?

Yes

Please fill out the information below.

Please skip to the next section.

Health Insurance Carrier:

Policy #:

Health Insurance Card: Please take a picture of your Health Insurance Card and attach it here! Front and Back!

Add file

Please upload a file

Section1.4 Attorney Information

Do you have an attorney representing you?

Yes

Please fill out the information below.

Please skip to the next section

Attorney's Name:

Attorney's Telephone:

Attorney's Address:

Section 2: Your Injury Information

Please explain where you have pain; be as specific as possible.

What hospital did you go to?

How many weeks?

How did you hit your head?

What bones are fractured or broken?

Please show on the body image where you are experiencing symptoms. Click on the body image where you have pain and fill out below.

If you need to change it just hit remove below on right hand side.

Section 3: Your Medical History

Have you previously received therapy for this injury?

Yes No

If yes, what is the name of the Therapy?

Are you currently taking any medication?

Yes No

If yes, what medications are you currently taking?

Do you have any pre-existing medical conditions?

Yes No

Please specify about your pre-existing medical conditions?

Is there anything else regarding your medical history that we should be aware of?

Yes No

Please tell us what else we should know about your medical history?

Section 4:A Auto Accident Information

Section 4:B Motor Cycle or Scooter Injury

Section 4:C Personal Injury or Pain (Health Insurance)

Date of the Accident:

Time of the Accident:

Which one of the following applies to you?

Driver *UBER Drive Passenger Pedestrian

Please describe your accident and what happened to you?

Was anyone else in this motor vehicle accident that will be having therapy at Wellness Medical Center?

Yes No

You may type in multiple names here.

Is there a Police report for this accident? Please bring the Police report in with you if you have it.

Yes No Not sure

Was the vehicle you were in a Rent-a-car? If you was in a rental you must let the Rental Company know of your accident. Please provide the rental claim info below.

Yes No Not sure.

Do you have the claim information of the vehicle you was in? This information is important so we may process your claim correctly.

Yes No Not sure.

Insured Person's Name:

Insurance Company's Name:

Claim #:

Policy #:

Is there any other information that we should know about your accident?

Do you have a prescription from your Primary care Doctor for Physical Therapy?

Yes No

Name of Physician

Physican's Telephone:

Please bring in any paperwork you may have from your Insurance company that may help process your medical claim.

Today's Date

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