Date*
MM slash DD slash YYYY
Patient Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Work Status*
- Full Time
- Part Time
- Retired
- Student
Marital Status*
- Single
- Married
- Divorced
- Widowed
Occupation*
Employer*
Employer Phone*
Emergency Contact (not living with you)
Name*
First Last
Phone*
Payment & Insurance Information (We need a Copy of your Insurance Card)
Date Of Birth*
MM slash DD slash YYYY
Primary Insurance*
ID#*
Policy Holder Name*
Relationship to Patient*
- Self
- Spouse
- Parent
- Other
Other Insurance or Attorney Name
Date of Birth*
MM slash DD slash YYYY
Name*
First Last
Relationship to Patient*
- Self
- Spouse
- Parent
- Other
ID/Claim #*
Policy Holder Name*
Date of Accident or Injury*
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*
MM slash DD slash YYYY
Printed Name of Patient Or Represntative*
First Last
Electronic Signature*
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*
MM slash DD slash YYYY
Printed Name of Patient Or Represntative*
First Last
Electronic Signature*
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*
MM slash DD slash YYYY
Printed Name of Patient Or Represntative*
First Last
Electronic Signature*
New Patient Questionaire
Date*
MM slash DD slash YYYY
Patient Name*
First Last
What is The Reason for Your Visit Today?*
How Long Have You Had the Symptoms?*
Does Anything Make Your Symptoms Better?*
Does Anything Make Your Symptoms Worse?*
Medications (Please List Below)*
Allergies: Please List Below*
Surgical History*
Family History
Please state whether your parents are living or deceased. If living, list all health conditions. If deceased, list age & cause of death.
Mother*
Father*
Social History
Are You:*
- Single
- Married
- Widowed
- Divorced
How Many Biological Children Do You Have?*
How Many Stepchildren Do You Have?*
Do You Smoke?*
- Yes
- No
If Yes, How Many Cigarettes Do You Smoke Per Day
Do You Drink Alcohol?*
- Yes
- No
If Yes, How Much & How Often
Work History
Are you Currently Working*
- Yes
- No
If Yes, What Is Your Occupation
Are You Disabled?*
- Yes
- No
If Yes, How Long Have You Been Disabled?
What Caused You to Become Disabled?
Review Of Systems
Please Select Yes if Any of the Following Apply to You
Associated/Constitutional: Loss of appetite*
- Yes
- No
Hematologic/Lymphatic: Anemia, Hepatitis*
- Yes
- No
Endocrine: Diabetes, Thyroid, Weight change*
- Yes
- No
Allergic/Immunologic: Allergies, Cancer*
- Yes
- No
ENT: Decreased hearing, Ringing in ear, Sinus trouble, Difficulty swallowing*
- Yes
- No
Eyes: Double vision, Blurred vision, Failing vision*
- Yes
- No
Lungs/Respiratory: Asthma, Wheezing, Shortness of breath*
- Yes
- No
Heart/Cardiovascular: Chest pain, High blood pressure, Heart murmur, Irregular pulse*
- Yes
- No
ABD/Gastrointestinal: Heart burn, Gout, Nausea, Vomiting, Abdominal pain, Diarrhea, Constipation, Hemorrhoids*
- Yes
- No
GENT/Genitourinary: Overnight urination, Urine infections*
- Yes
- No
BJE/Musculoskeletal: Joint/muscle pain, Arthritis, Back pain, Neck pain*
- Yes
- No
Skin: Rash, Lumps, Itching*
- Yes
- No
Neuro: Seizures, Tremors, Weakness, Numbness, Headaches, Memory loss*
- Yes
- No
Psych: Depression, Moodiness, Difficulty sleeping, Anxiety*
- Yes
- No
hCaptcha*

CONTACT

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

CONTACT

Patient Information

Emergency Contact (not living with you)

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

Other Insurance or Attorney Name

Consent to Treatment

Disclosure of Information

Acknowledgement and Agreement

Notice of Privacy Practices (HIPPA)

Guarantee of Payment

New Patient Questionaire

Family History

Social History

Work History

Review Of Systems

CONTACT