Registration Form

Appointment Date *

Last Name (include Jr., II, III, etc., if applicable) *

First Name *

M.I.

Address

City

State/Province

Zip/Postal

Country

Phone

Email

Date of Birth *

Social Security # (last 4 digits) *

Height *

Weight *

Marital Status *

Employer *

Occupation *

Work Phone #

If patient is a minor (under the age of 18), please check box and complete additional questions.

Name of School Patient is Attending *

Any patient under the age of 18 must be accompanied by a parent or appointed guardian for ALL appointments.

Father's Information

Last Name (include Jr., II, III, etc., if applicable) *

First Name *

M.I.

Address *

Address

City

State/Province

Zip/Postal

Home Phone #

Cell Phone # *

Email

Date of Birth *

Age

Social Security # (last 4 digits)

Marital Status *

Drivers License #

Spouse's Name

Employer's Name

Employer's Phone #

Employer's Address

City

State/Province

Zip/Postal

Mother's Information

Last Name *

First Name *

M.I.

Address *

Address

City

State/Province

Zip/Postal

Home Phone #

Cell Phone # *

Email

Date of Birth *

Age

Social Security # (last 4 digits)

Marital Status *

Drivers License #

Spouse's Name

Employer's Name

Employer's Phone #

Employer's Address

City

State/Province

Zip/Postal

In The Event The Parent/Guardian Is Not Present

Spouse's Name

Spouse's Date of Birth

Spouse's Social Security # (last 4 digits)

Spouse's Place of Employment

How did you hear about us? *

Extremity Affected *

Left

Right

Hand Dominance *

Left

Right

Location of Symptoms?

What type of injury or condition is this? *

Auto Accident/Third Party Liability

OtherOther

Worker's Compensation

Auto Accident/Third Party Liability Information

Please contact the responsible party for accurate billing information BEFORE your appointment with our specialist to avoid receiving a billing statement. Please note: The belief that an auto insurance carrier or third party is responsible for your condition does not guarantee payment. For this reason, we require all patients provide private health insurance information (if applicable), including insurance card(s) at the initial visit. This will expedite processing your claims in the event of an auto or third party insurance denial. Also, if your health insurance is an HMO or requires an authorization to be seen by a specialist, we strongly suggest contacting your primary care physician to obtain a referral prior to your appointment for the best benefits available to you in case your auto or third party liability claim is denied or exhausted.

State Accident Occurred In *

Type of Third Party Liability Accident *

Auto

Home Owner's

OtherOther

What insurance coverage should we bill first? *

Third Party Liability Insurance

Personal Health Insurance

Insurance Carrier's Name

Phone #

Claims mailing address or PO Box

City

State/Province

Zip/Postal

Claim #

Adjuster

Insured Name

Date of Birth

Worker's Compensation Information

Please contact your employer for accurate billing information BEFORE your appointment with our specialist to avoid receiving a billing statement. Please note: The belief that your injury is work related does not guarantee payment by your employer’s work compensation insurance carrier. For this reason, we require all patients provide private health insurance information (if applicable), including insurance card(s) at the initial visit. This will expedite processing your claims in the event of a worker’s compensation denial. Also, if your health insurance is an HMO or requires an authorization to be seen by a specialist, we strongly suggest contacting your primary care physician to obtain a referral prior to your appointment for the best benefits available to you in case your worker’s compensation claim is denied.

If Worker’s Compensation, have you filed a FIRST REPORT of injury with your employer? *

Yes

No

State Accident Occurred In *

Employer Responsible for Injury *

Address *

Address

City

State/Province

Zip/Postal

Phone # *

Insurance Carrier's Name *

Phone # *

Claims mailing address or PO Box *

Claims mailing address or PO Box

City

State/Province

Zip/Postal

Claim # *

Adjustor *

When did this injury or condition occur or begin *

How did the pain that you are currently experiencing occur? *

Slow progressive onset

Slow progressive onset with significant worsening after an accident or event

Sudden onset without an accident or definable event

Sudden onset with accident or definable event

Description of how this occurred *

Symptoms you are having *

Are you having numbness and pain? *

Yes (If so, where is it located specifically?)Yes (If so, where is it located specifically?)

No

Level of Symptoms *

Please move the blue box and select your current level of pain (zero being no pain, 10 being most severe)

What makes it better/worse? *

What activities are difficult to perform? *

What treatment have you had for this? *

Surgery

Therapy

None

OtherOther

Has this been associated with any other problems elsewhere on your body? *

Yes (If yes, please describe)Yes (If yes, please describe)

No

Are you involved in any legal action regarding your physical complaint?

Yes

No

Are you presently receiving psychiatric treatment?

Yes

No

Previous psychiatric treatment