axonhealthassociates-New-Patient-Form

PATIENT CASE HISTORY
Please select a location*

Wall St OfficeWest 34th St OfficeWilliam St Office
Name*

First NameLast Name
DOB *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
# of children
Marital Status

SingleMarriedDivorcedWidow
Work # *
Spouse’s Name
Home #*
Spouse’s Phone
Please enter a valid phone number.
E-mail *
example@example.com
Employer
Referred by:
SS#
HEALTH INFORMATION
What is your major complaint?
Other complaints:
How long have you had this condition (approximate date)?
Have you had this or similar conditions in the past?
What activities aggravate your condition?
Is this condition getting progressively worse?

YesNoCONSTANTCOME & GOES
Is this condition interfering with your:

WORKSLEEPDAILY ROUTINEOTHER
How long has it been since you really felt good?
Other doctors who treated this condition:
List surgical operations and years:
Drugs you now take:

NERVE PILLSPAIN KILLERSMUSCLE RELAXERS"PEP” PILLSTRANQUILIZERSINSULINBIRTH CONTROLOTHER
Age of mattress
Mattress

COMFORTABLEUNCOMFORTABLE
Are you wearing:

HEEL LIFTSSOLE LIFTSINNER SOLESARCH SUPPORTS
Have you been in an auto accident?

PAST YEARPAST 5 YEARSOVER 5 YEARSNEVER
Describe
Date of Last Physical Examinatio

MonthDayYear
Date
Have you ever suffered from?
1. Dizziness

YesNo
2. Backaches

YesNo
3. Heart trouble

YesNo
4. Diabetes

YesNo
5. Arthritis

YesNo
6. Headaches

YesNo
7. Asthma

YesNo
8. Neuritis

YesNo
9. Digestive Disorders

YesNo
10. Nervousness

YesNo
11. Sinus trouble

YesNo
12. Neck Pain

YesNo
INSURANCE INFORMATION
Is your condition due to an auto accident or job related injury?*

YesNo
Do you have health insurance?*

YesNo
Name of Company*
Policy #*
I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this Medical Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this Medical Office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.
Patient’s Signature:*

Clear
Date*

MonthDayYear
Date
Guardian or Spouse Signature:*

Clear
SS#
ASSIGNMENT/DIRECT PAYMENT TO DOCTOR PRIVATE/GROUP ACCIDENT AND HEALTH INSURANCE
PATIENT:
EMPLOYER:
GROUP NO:
SSN/ID:
I hereby instruct and direct my insurance company to pay by check made out and mailed to:

45 West 34th Street, Suite 1201 61 Broadway, Suite 900

New York, NY 10017 New York, NY 10006

Phone 646.454.8264 Phone 212.248.0077

100 William Street, Suite 1215 25 West 45th Street, Suite 507

New York, NY 10038 New York, NY 10036

Phone 212.509.3333 Phone 212.328.9444

If policy provisions prohibit direct payment to physician, I hereby also instruct and direct you to make out the check to me and mail to one of the addresses above. Payment is for the professional or medical expense benefits allowable, and otherwise payable, to me under my current insurance policy as payment toward the total charges for professional services rendered.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in current manner, any balance of said professional services charges over and above this insurance payment. A photocopy of this Agreement of Rights and Benefits shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
Date*

MonthDayYear
Date
Signature*

Clear
Signature of Policy Holder
Witness
PATIENT’S PREGNANCY EVALUATION FORM

Dear Patient,

In order for us to fully evaluate you we are required to take x-rays of some part(s) of your body. It has been predicted that an unborn child in its first trimester would be more sensitive to radiation than an adult. In order to insure that accidentally, knowingly or otherwise, no Fetus (unborn child) be exposed to radiation from x-ray machines, we ask you to provide us with the following information. We thank you for the information and this information is strictly confidential and is solely used for the purpose it is intended.
Date

MonthDayYear
Date
NAME:
DATE OF THE ONSET OF LAST MENTRUAL PERIOD:

MonthDayYear
Date
IS THERE ANY CHANCE THAT YOU MAY BE PREGNANT?

YesNo
To the best of my knowledge, I am not pregnant and by providing this application for Physician/Technologist has informed me of the effects of Radiation to the Unborn baby and me by signing below have consented to taking the x-rays of my body parts for further studies.
SIGNATURE:*

Clear
AXON HEALTH ASSOCIATES PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby give my consent for Axon Health Associates to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

Axon Health Associates notice of privacy practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Axon Health Associates reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Axon Health Associates, 120 East 42nd Street, NY, NY 10017.

With this consent Axon Health Associates may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.

With this consent Axon Health Associates may mail to my home or other alternative location any items that assist the practice in carrying out TPO such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With the consent of Axon Health Associates may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Axon Health Associates restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Axon Health Associates to use and disclose of mu PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Axon Health Associates may decline to provide treatment to me.
Patients Name*
Date*

MonthDayYear
Date
Signature*

Clear
Signature of patient or legal Guardian
Print Name of Patient or Legal Guardian
CONSENT TO TREAT FORM

1.    I give permission for Axon Health Associates to give me Chiropractic and Physical Therapy.

2.    I allow Axon Health Associates to file for insurance benefits to pay for the care I receive.

I understand that:

·       Axon Health Associates will have to send my medical record information to my insurance company.

·       I must pay my share of the costs.

·       I must pay for the cost of these services if my insurance does not pay or I do not have insurance.

3.    I understand:

·       I have the right to refuse any procedure or treatment.

·       I have the right to discuss all Chiropractic and Physical Therapy with my clinician.
Patients Name*
Date*

MonthDayYear
Date
Patient's Signature*

Clear
Signature of patient or legal Guardian
Parent or Guardian Signature Date(for children under 18)

Clear
Signature of patient or legal Guardian
Print Name*
Should be Empty:

PATIENT CASE HISTORY