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

Patient Intake Instructions

Welcome to Wellness Medical Center!

Please follow these steps to complete your intake form:

Select the type of injury for which you are seeking treatment.
Complete all required fields and any additional sections that appear.
Review your information for accuracy.
Submit your completed form securely.

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 upload a clear photo of your valid government-issued photo ID (such as a driver's license or state identification card).

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.

Employer's Name:

Employer's Telephone #:

Employer's 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 #:

Please upload clear photos of the front and back of your current health insurance card. Front of card

Add file

Please upload a file

Back of card

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 describe where you are experiencing pain or other symptoms. Be as specific as possible.

What hospital did you go to?

How many weeks pregnant are you?

How did you hit your head?

If yes, which bones were fractured?

Please click on the body diagram to indicate where you are experiencing pain or other symptoms. For each area selected, specify the type of pain, severity, and a brief description of your symptoms.

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

What type of provider(s) have you seen?

Please list the name(s) of the facility/provider(s):

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

If yes, please describe your pre-existing medical conditions.

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

Yes No

If yes, please provide any additional relevant 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 Passenger Delivery Driver Uber/Lyft Driver Pedestrian Commercial Vehicle Driver Other

Please briefly describe the accident, including how it happened and any immediate injuries or symptoms you experienced.

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.

Was a police report filed for this accident? Please bring the Police report in with you if you have it.

Yes No Not sure

Files If available, please upload the police report.

Add file

Please upload a file

Was the vehicle involved in the accident a rental vehicle? 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 auto insurance claim information for this accident? This information is important so we may process your claim correctly.

Yes No Not sure.

Insured Person's Name:

Insurance Company's Name:

Claim Number:

Policy Number:

Adjuster Name:

Adjuster Phone Number:

Adjuster Email Address:

Is there anything else we should know about your accident

Do you have a referral or prescription from a healthcare provider for physical therapy

Yes No

Referring Healthcare Provider's Name"

Referring Healthcare Provider's Phone Number

Upload Referral or Prescription

Add file

Please upload a file

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

Emergency Contact

Emergency Contact Name

Relationship to Patient

Emergency Contact Phone Number

Today's Date

I confirm that the information I have provided is accurate and complete to the best of my knowledge.

Thank you for completing your intake form.

Our team will review your information and contact you if any additional details are needed.

Your information will be encrypted.