EMC Intake Forms

Select Your Language In The Top Right Corner
Intake Paperwork
Name*

First NameLast Name
Todays Date*

MonthDayYear
Date
DATE OF INCIDENT*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Date of Birth

MonthDayYear
Date
Auto Insurance Company
Policy Number (If you know it)
Claim Number (if you know it)
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Treating Physician*

First NameLast Name
Attorney Name*

First NameLast Name
Signature*

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If you are using a touch screen feel free to use your finger if using a computer or laptop please use your mouse. Good luck with that :)
INFORMED CONSENT FOR TELEMEDICINE CONSULTATION:

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with a licensed medical provider. Telemedicine involves using electronic communications to enable healthcare providers at different locations to share individual patient medical information to improve patient care. Details of your medical history, examinations, and diagnostic tests will be discussed using interactive video, audio, and/or telecommunications technology. The information may be used for diagnosis, therapy, follow-up, and/or education. All existing laws regarding access to medical information and copies of your medical records apply to this telemedicine consultation. I understand that my telemedicine consultation may include video, audio and/or digital photos and may be recorded. I understand that this telemedicine consultation is not a complete substitute for in-person visits with a medical provider and that certain medical conditions may require direct physical examination.

Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and state law apply to information disclosed during this telemedicine consultation.

Patient Consent to the Use of Telemedicine:

I hereby give my informed consent for the use of telemedicine in my medical care. I hereby authorize my healthcare provider(s) at MyEMCDoc, LLC., to provide medical consultation via telemedicine in the course of my diagnosis and treatment.
LIMITED POWER OF ATTORNEY

POWER OF ATTORNEY TO ENDORSE CHECKS AND/OR TO SIGN ANY PAPER WHICH WILL ENHANCE OR EXPEDITE PAYMENT TO PROVIDER FOR SERVICES RENDERED INCLUDING BUT NOT LIMITED TO A RELEASE OF MEDICAL RECORDS and ASSIGNMENT OF BENEFITS/AUTHORIZATION TO PAY.
MEDICAL RECORDS RELEASE

Patient Name: {name}

Date of Birth: {dateOf56}

Date of Accident: {dateOf}

A photocopy of this document shall be sufficient to authorize any person or medical office having records of medical treatment, services, or supplies pertaining to me to release true copies of same to My EMC Doc, LLC or any insurer providing coverage to me in connection with the processing of any claim for benefits made by me or by the assignee herein. A photocopy of this document shall be as binding as an original signature page. The undersigned does hereby ratify and confirm, and all actions were taken by the said attorney in accordance with this special power and which said attorney shall do or cause to be done by virtue of these present.

I hereby permit My EMC Doc, LLC to obtain any pertinent medical records related to this incident.

All records will be uploaded to the Physician Portal by your treating physician.
Signature*

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ASSIGNMENT OF BENEFITS

I, {name}, hereby authorize

Payable and mailed directly to:

My EMC Doc

931 Village Blvd. Ste 135

West Palm Beach, FL 33409

The medical benefits otherwise payable to me for their services, but not to exceed the charges of those services. I hereby IRREVOCABLY ASSIGN to MY EMC DOC any rights and benefits under any policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statues for any service and or charges provided by MY EMC DOC, LLC.
Signature*

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Use your computer/laptop mouse to write your signature. If you are on a touchscreen device, feel free to use your finger.
HISTORY & COMPLAINTS
Patient Name: {name}

Date of Incident: {dateOf}
Were you the driver or passenger*

DriverPassengerBack Seat
Briefly describe how the accident happened.*
Please describe your current complaints*
Draw on the Image to show where you are in pain. (If the Image Disappears, Please Skip this section)
Additional neurological symptoms

HeadacheLightheadedDouble VisionMemory LossBlurred VisionRinging in EarsLoss of BalanceDizzinessSensitive to LightTMJ / Jaw Symptoms
Did you go to the Hospital after the incident?

YesNo
Did you have an MRI for the injuries related to this incident?

YesNo
Do you know the results of the MRI? If so, please indicate below.
Are you currently taking any medication either OTC or Prescription? If yes please list. If none type None. Be as specific as possible.*
Please Upload a photo of your ID (Driver’s license, Passport, or other government issued ID.) Or text the photo to (888) 936-2362

Simply take a photo of your ID on your phone and upload it here.
Cancelof
Signature*

Clear
Use your computer/laptop mouse to write your signature. If you are on a touchscreen device, feel free to use your finger.
Should be Empty:

Intake Paperwork

INFORMED CONSENT FOR TELEMEDICINE CONSULTATION:

HISTORY & COMPLAINTS