New Patient Intake Form

360 Medical Consent to Treat

Lauren Tortorici, DC | Sharmin Sultana, DC | Louis Angulo, DC | Earvin Paul, DC

Dana Harris, DC | Goli Hiekali, PT, DPT | Anna Potapova, PT, DPT

Bahr Rubinstein, DC

I hereby consent to the performance of chiropractic treatment, including but not limited to joint and soft tissue mobilization, physiotherapy modalities, stretching, and therapeutic exercise, by the Doctor of Chiropractic named above and/or other licensed Doctor of Chiropractic who now or in the future work at any of the 360 Medical Consulting’s clinics or offices. By signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
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Notice of Privacy Practice Patient Acknowledgement

I understand that, under the Health Insurance Portability Accountability of 1996, I have certain rights to privacy in regard to my protected health information (PHI). I have received, read and understand The Notice of Privacy Practices. The practice reserves the right to change the terms of its Notice of Privacy Practices. I understand the practice will provide current notice of Privacy Practices on request.
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If you are unable to do so, you must bring these to your first visit.
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Firm Sponsored Activities Release and Waiver I wish to participate in certain facilities, activities and benefits (including, without limitation, wellness treatments and classes, physical therapy, nursing services, chiropractic services, bicycle rental and/or storage and access to shower and dressing rooms, common rooms and terraces, participation in indoor and outdoor recreation and sports, each, a “Sponsored Activity”) maintained or sponsored in whole or in part by MillenniumManagement LLC, MPG Operations LLC, Integrated Holding Group LP and their affiliates (collectively, the“Firm”) that is outside of the course and scope of my ordinary work duties. I hereby acknowledge and agree that I am a voluntary participant in all Sponsored Activities, and inconsideration of being given access to any Sponsored Activity do hereby voluntarily and knowingly assume any and all risks which I might suffer as a result of my participation therein, and hereby indemnify and hold harmless the Firm, and its service providers and suppliers (collectively, together with their respective successors, assigns, agents, employees, officers and principals, the “Releasees”), on behalf of myself and my personal representatives, heirs, administrators, executors, successors and assigns, from and against any claim or demand due to illness, injury, damage or loss sustained by me now or in the future resulting from or pertaining or incidental to my taking part in any Sponsored Activity, whether during or outside working hours and on or off work premises, and I do hereby expressly waive and renounce any and all such claims and demands of any nature whatsoever that may be asserted against Releasees in connection with, relating to or as a result of anySponsored Activity. I acknowledge and agree that it is my responsibility to determine whether it is appropriate for me to participate in any Sponsored Activity and, if necessary, to consult with my personal physician or other health care provider to determine whether I should participate. I further declare that I have read the foregoing carefully and am fully aware of all the circumstances and ramifications connected with the subject of this Release and Waiver.*

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Musculoskeletal Intake Form

Review of Systems

360 Medical Consent to Treat

Notice of Privacy Practice Patient Acknowledgement

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