• Date Format: MM slash DD slash YYYY
  • Patient Information

  • Emergency Contact (not living with you)

  • Payment & Insurance Information (We need a Copy of your Insurance Card)

  • Date Format: MM slash DD slash YYYY
  • Other Insurance or Attorney Name

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Consent to Treatment

    The undersigned acknowledges that he/she has requested healthcare services from the Clinic of Neurology, Ltd. (Dr. Neal Pollack). I consent to diagnostic procedures and medical care as necessary in the judgment of my doctor. I understand that my doctor will explain to me the purpose of, the benefits, and the usual risks and hazards involved in the diagnosis and treatment of any illness or injury, as well as alternative courses of treatment. I further understand that I have the right to refuse any suggested examinations, tests, or treatment. I acknowledge that no guarantees have been made to me as to the results of treatment.
  • Disclosure of Information

    All information provided to the Clinic of Neurology, Ltd. is strictly confidential except for the following circumstances: 1. Your insurance company requests information about your treatments in order to process a claim or certify care; 2. The patient authorizes the release of information by signing a release form naming the specific person to receive the information; 3. Certain circumstances where we are required by law to release patient information such as, but not limited to, court subpoena, suspected abuse, etc.
  • Acknowledgement and Agreement

    I have read the above information and thoroughly acknowledge and agree to all of the above information.
  • Date Format: MM slash DD slash YYYY
  • Notice of Privacy Practices (HIPPA)

    I acknowledge that I have received or was offered a copy of the Clinic of Neurology, Ltd.’s Notice of Privacy Practices.
  • Date Format: MM slash DD slash YYYY
  • Guarantee of Payment

    I understand that I am responsible for payment of all fees and services rendered. I have been advised that if my health insurance carrier declares that the services I receive are not considered reasonable and medically necessary, I will be responsible for payment of these services. I authorize payment of benefits from my insurance carrier directly to the Clinic of Neurology, Ltd. Please note payment is required at the time of service. A $25.00 fee will be charged for returned checks. I have read and understand my financial responsibilities outlined in this document.
  • Date Format: MM slash DD slash YYYY
  • New Patient Questionaire

  • Date Format: MM slash DD slash YYYY
  • Family History

    Please state whether your parents are living or deceased. If living, list all health conditions. If deceased, list age & cause of death.
  • Social History

  • Work History

  • Review Of Systems

    Please Select Yes if Any of the Following Apply to You

CONTACT

OUR PERSONALIZED WELLNESS APPROACH IS WHAT SETS US APART WITH
PAIN TREATMENTS PLANS DESIGNED AROUND EACH PATIENT’S NEEDS.

CONTACT