Phone Consult Intake

Intake Phone Consult

Dr. John Gatell D.C.,M.S.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Email*
example@example.com
Mobile Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height*
Weight*
Sex*
Male, Female, etc.
If Female, Date Started of Menses:

MonthDayYear
Date
Current Activities:*
Guardian’s Name:
Relationship to Guardian:
Height of Dad:
Height of Mom:
How did you hear about Dr. John:*
Current Condition:*
Date of Diagnosis:*

MonthDayYear
Date
By Who:*
Degree of curvature when Diagnosed:*
What was the recommendation?*
When diagnosed, what treatment did you do?*
What were the results?*
Who is your current Doctor & what do they recommend:*
Date of your most current x-ray?*

MonthDayYear
Date
Degree measured at that time?*
Any other Doctors that you have seen for this condition and what did they recommend?*
Any Family History of Condition:*
If yes, describe:
Any other Health Conditions?*
Any Surgeries:*
If yes, describe:
Any injuries, trauma or broken bones:*
If yes, describe:
Additional information you would like Dr. John to know:*
I understand that this is a phone call consultation and is NOT meant to replace a complete exam or evaluation. The intent of this phone consultation is not to diagnosis or treat any condition, but merely to review your case and discuss the available options, answer questions, and discuss the current treatment models. I understand the doctor doesn't have all data necessary to make a complete diagnosis or prognosis regarding treatment, exams, x-rays, and any other testing.
Patient/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Do you already have a phone consult already scheduled?*

YesNo
Requested Appointment Date & Time:
Have you sent over/uploaded x-rays or reports to review for the call:*

YesNo
File Upload or go back to “New Clients” tab to upload files: www.AtlantaScoliosisCenter.com

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Should be Empty:

Intake Phone Consult