Specialty Clinic

Specialty Clinic

| Pain Management | Orthopedic | Podiatry | Dermatology | Hypertension | | Physical Therapy |
Appointment Date

MonthDayYear
Date
Consent and Privacy Notices

Consents and permissions to share information*

	Yes	No
I give the staff of Clinic with a Heart the permission to treat me or my minor child.
I understand that if I am prescribed medicine it will be from a limited list of available medications and will be for a maximum 90-day supply.
I understand that Clinic with a Heart does not prescribe narcotics or controlled substances.
I give permission for Clinic with a Heart to share my health information with referral agencies as needed.
I understand that medical information I share with Clinic with a Heart will be kept confidential.

Signature*

Clear
Patient Name*

First NameLast Name
Patient Birthday*

MonthDayYear
Patient Gender*

FemaleMaleOther
Patient Phone Number*
Must be a phone that we can contact the patient. Must be a United States contact number.
What type of phone is the phone number for?*

Cell PhoneLandlineOther
Medical History

Medications and Allergies are included in the information below.
Have there been any changes to your health since your last visit to Clinic with a Heart?*

YesNo
Please explain the changes to your health*
Does the patient have insurance?*

YesNoOther
Does the patient feel safe?*

YesNo
Do you smoke? (cigarettes, e-cigarettes, vapes, etc.)*

YesNo
How much do you smoke?
How often do you drink Alcohol in a week?

Never1-23-45 or more times
How often do you use recreational/street drugs in a week?

Never1-23-45 or more times
What drugs do you use?
Do you have any known allergies?*

YesNo
Please list any allergies below. *
Do you take medication(s)? (Including vitamins, supplements, or over-the-counter medicines)*

NoYesOther

What medicine do you currently take? *

Medical History