Nurse Practitioner Intake Form

Nurse Practitioner Intake Form

Millennium Wellness Center
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth *

MonthDayYear
Date
What is your age?*
What is your gender?
Marital Status
Phone Number:*
Email*
example@example.com
Which department do you work in?*
Primary Care Physician:
Emergency Contact/ Relationship*
Emergency Contact Phone*

Is this condition related to an auto accident, work-related or other personal injury?*
If yes, please briefly describe and let us know if you have any pending litigation regarding this condition:
What is the purpose of your appointment?*
When did this condition begin?*
YesNo
If Yes, When?
Who was the doctor?
What type of treatment did you receive?
What were the results?
Have you had imaging/testing for this condition?
(e.g. X-ray, MRI, Bloodwork, etc.)
If YES, where?

360 Medical Nurse Practitioner Consent to Treat

I, with my signature authorize the Nurse Practitioner on staff for MLP Wellness/360 Medical, to provide medical care for me. This care may include services and supplies related to my health and may include (but is not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, counseling, assessment, or review of physical or mental status/function of the body and/or dispensing of drugs, devices, equipment, or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.
Signature*

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Date

MonthDayYear
Date
Notice Of Privacy Practices 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.
Signature*

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Date

MonthDayYear
Date
Please either upload or take pictures of your photo ID and insurance card below.

If you are unable to do so, you must bring these to your first visit.
Upload Photo of ID

Cancelof
Upload Photo of Insurance

Cancelof
Upload Photo of ID
Upload Photo of Insurance
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 Millennium Management 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 in consideration 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 any Sponsored 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.
Signature*

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Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Nurse Practitioner Intake Form

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