New Patient Intake Form

1
Patient Name* This field is required.
First Name
Last Name
2
Patient Date of Birth* This field is required.
Month
Day
Year
3
Patient Gender* This field is required.
Please Select
Please Select
Male
Female
Transgender
Other
4
Patient Height (inches)* This field is required.
5
Patient Weight (lbs)* This field is required.
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Patient Phone Number* This field is required.
Area Code
Phone Number
8
Patient E-Mail
9
Emergency Contact* This field is required.
First Name
Last Name
10
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
11
How did you hear about us?* This field is required.
Please Select
Please Select
Referral
Radio
Facebook
Instagram
Other
12
If referred to us, please list name of person who referred you.
13
What brings you to Marino Health and Wellness?* This field is required.
14
Have you ever had (Please check all that apply)* This field is required.
Anemia
Asthma
Arthritis
Diabetes
Epilepsy Seizures
Fainting Spells
Heart Disease
Heart Attack
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Thyroid Problems
Bleeding Disorders
Lung Disease
Emphysema
Lyme Disease
Joint replacement
Autoimmune disease
Neuropathy/loss of normal skin sensation
Ulcer Disease
None of the above
15
Have you ever been diagnosed with Cancer?* This field is required.
YESNO
16
If you have been diagnosed with cancer, please list cancer type.
17
Have you ever been diagnosed with Lyme disease?* This field is required.
YESNO
18
For women only, are you pregnant or nursing?
YESNO
19
Please list any other medical conditions you may have that are not listed:
20
Do you have any history of the following?* This field is required.
Pacemaker
Hormone pellets
Hearing aids
Medical/medical devices implanted
IUD implanted
None of the above
21
Please list any surgeries and dates of each
22
Are you currently taking any medications?* This field is required.
YESNO
23
If you are currently taking any medications, please list all of your Current Medications, Dosage and Reason for Taking
24
Do you have any drug allergies?* This field is required.
YESNO
25
If you have any drug allergies, please list and include reaction:
26
Do you have a latex allergy?* This field is required.
YESNO
27
Do you have any other allergies?* This field is required.
YESNO
28
If yes to other allergies, please list and include reaction:
29
Current stress level* This field is required.
I have no stress
I have mild stress
I have moderate stress
I have severe stress
30
How many times a week do you exercise?* This field is required.
Never
1-2 days
3-4 days
5+ days
31
How many glasses of water do you drink daily?* This field is required.
< 8 oz./day
8-16 oz/day
16 - 32 oz/day
32-64 oz/day
> 64 oz/day
32
How many glasses of water do you drink per day?* This field is required.
33
Dietary habits* This field is required.
Not Good
Moderately Health
Very Healthy
34
Alcohol Consumption* This field is required.
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
1-2 glasses/week
2-4 glasses/week
35
Caffeine Consumption* This field is required.
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
36
Do you drink soda?* This field is required.
YESNO
37
How many hours of sleep do you get per night on average?* This field is required.
38
Do you smoke?* This field is required.
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Ex-smoker
39
Recreational Drug Use* This field is required.
YESNO
40
Would you also like information on any of the following:
Joint pain
Anti-aging/skin
IV therapy
Hair loss treatments
Tattoo removal
Body sculpting
Dermal filler or Botox/Jeuveau
Laser hair removal
Erectile dysfunction (men)
Orgasmic disorder (women)
Hormone therapy
Weight loss
41
Signature and Date* This field is required.By signing below, I confirm that I have provided my complete medical history and health/lifestyle habits to the best of my ability. I understand that it is my responsibility to notify my provider if there are any changes to my health.
Clear
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Health and Insurance Portability and Accountability Act (HIPAA)* This field is required.Health Insurance Portability & Accountability Act (HIPAA) Consent for Purposes of Treatment, Payment and Healthcare Operations I consent to the use or disclosure of my protected health information by Marino Health & Wellness, PLLC for the purpose of diagnosing or providing treatment to me, obtaining payment of my health bills or to conduct health care operations of Marino Health & Wellness, PLLC. I understand that diagnosis or treatment of me by Marino Health & Wellness, PLLC may be conditioned upon my consent as evidenced by my signature on this document. I understand that I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations. Marino Health & Wellness, PLLC is not required to agree to the restrictions that I may request. However, if Marino Health & Wellness, PLLC agrees to a restriction that I request, the restriction is binding with Marino Health & Wellness, PLLC. I understand Marino Health & Wellness, PLLC uses a variety of electronic communication methods including phone, text messages, email, etc. to communicate with me for the limited purposes appointments, available services, and other healthcare related communications. I authorize Marino Health & Wellness, PLLC to disclose limited protected health information to other persons who may answer my electronic communications such as phone, text messages, or e-mail. These may include information about appointments, available services, or other healthcare related communications. I have the right to revoke this consent, in writing, at any time, except to the extent Marino Health & Wellness, PLLC has taken action in reliance on this consent. My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me I understand I have a right to review Marino Health & Wellness, PLLC’s Notice of Privacy Practices before signing this document. Upon request, a copy of the Marino Health & Wellness, PLLC’s Notice of Privacy Practices is available to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Marino Health & Wellness, PLLC. The Notice of Privacy Practices is also provided and available in the reception area and on the Marino Health & Wellness, PLLC web site at https://marinohealth.com. The Notice of Privacy Practices also describes my rights and the duties of Marino Health & Wellness, PLLC with respect to my protected health information. Marino Health & Wellness, PLLC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by accessing Marino Health & Wellness, PLLC’s website, calling the Marino Health & Wellness, PLLC office and requesting a revised copy be sent in the mail or requesting a revised copy at my next appointment.
Clear
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I authorize the sharing of my medical information including my comprehensive medical and treatment history and medical plan to the following person. Please include Name and Phone number. If you do not wish to share your medical information with anyone, please leave blank.
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Cancellation and Policies Agreement* This field is required.Cancellation Policy Once you have booked an appointment with us at Marino Health and Wellness it means that we have reserved time in our schedule exclusively for you. If you are unable to keep your scheduled appointment, we respectfully ask that you provide 24 hours advance notice by calling or texting our main number 603-336-2011. Cancellations sent via social media or email will not be accepted. Cancellations with less than 24 hours notice, will be subject to a $50 cancellation/rebooking fee, as will no show appointments, for the first offense. This includes cancellations due to illness. Additional late cancellations and no-shows will be subject to forfeiting the scheduling treatment and losing the entire amount paid for that session. Appointment Reminder Policy As a courtesy, to our patients we will send a text message reminder 24 hours prior to your scheduled appointment, should you not opt-out of text reminders. Should you choose to not provide us with your cell phone number, we are unable to offer you a reminder. Should our appointment reminder system fail for any reason or you do not receive a text reminder, it is still your responsibility to manage your appointment and adhere to our cancellation policy Arrival Policy If you are a new patient at Marino Health and Wellness, we kindly ask you to arrive 10-15 minutes early for your appointment to check in and fill out any additional necessary new patient paperwork. Otherwise, we ask our recurring patients to arrive on time or early for your scheduled appointment. We have reserved adequate time for your appointment, but it is based on your timely arrival. We will allow for up to a 10-minute grace period for unforeseen circumstances, but anything after this time frame will be subject to a rebooking charge of $50, or an abbreviated session. Refunds At Marino Health and Wellness, our services are customized to each of our patients, often sold as part of a package and irrevocable. As such, our treatments are non-refundable and non-transferrable. Should you decide not to continue with your specified treatment either before treatment has begun or in the middle of a package or series, we will gladly put the unused portion towards other products or services at Marino Health and Wellness or on a Marino Health and Wellness Gift Card. No refunds will be given in cash or back to the original form of payment. We believe the products we sell are of the highest quality and that you will enjoy them just as much as we do. All of our product sales are final. Should you receive a damaged product, please contact us within 3 days of receipt, and will exchange it for the same product. Due to health regulations, we cannot accept returns on used products. Our policies allow us to provide excellent quality care to our existing and future patients. We appreciate your understanding. By signing below, I acknowledge that I have read and understand the cancellation, arrival and refund policies at Marino Health & Wellness. I understand that I will be charged for cancelled or missed appointments, as mentioned above. We observe strict privacy policies and will not disclose this information to any other party.
Clear
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Signature and Date* This field is required.By signing below, I confirm that I have provided my complete medical history and health/lifestyle habits to the best of my ability. I understand that it is my responsibility to notify my provider if there are any changes to my health.
Clear
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