NEW PATIENT FORM: PAIN

NEW PATIENT FORM: PAIN
Hello and welcome to Bermuda Pain Relief Center. We ask that you help us by providing as much information as you can regarding your current condition and ongoing treatment as well as any prior diagnostic tests, treatments and medical records that you may have had. This questionnaire is designed to step you through all areas of your past and present medical care. Please complete as much of this form as you are able to prior to your first visit, so that we can use this information at the time of your first visit to get a complete picture of you and your overall condition. Please do not hesitate to ask any of our staff or physicians for assistance if you have any questions or concerns. We look forward to meeting you.
Name*
Date of birth*

DayMonthYear
Date
E mail*
example@gmail.com
Have you previosly been a patient a the Bermuda Pain Relief Center*

YesNo

Have any of your details changed (Home address, health insurance provider, employer, GP)

NOYES

Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home
Telephone number
Mobile*
Work
Emergency Contact Name & Number*
Name of Employer
Insurance Company*
Certificate #*
Policy #*
Type of health insurance plan*

Basic Plan (Hospital coverage only)Major Medical planElite Medical Plan
Referring Physician*
General Practitioner*
Other physicians involved in your care
Pharmacy of preference

Patient information
I , First Name* Last Name* hereby grant permission to Bermuda Pain Relief Center to release my health information, encompassing, but not restricted to, office notes, laboratory results, and radiology findings. Additionally, I consent to the utilization of my image as an integral component of my medical record by the Bermuda Pain Relief Center.
Your medical records will only be shared with your General Practitioner, your referring Physician and any other health care provider of your preference.
Please advise us if you would prefer us to limit the sharing of your medical records.
FINANCIAL POLICY AND AGREEMENT
Bermuda Pain Relief Center is committed to providing you with the best in Pain Management Services. Our fees are based on current specialist pricing.
CANCELLATION POLICY
We ask that you make your appointments carefully to ensure that you are able to keep them. After three no shows you will not be able to reschedule with Bermuda Pain Relief center. For cancellations with less than 24 hours notice you will be charged 50% of the consultation fee. If you arrive past your scheduled appointment time, you may be asked to reschedule.
I, hereby grant permission to Bermuda Pain Relief Center to release my health information, encompassing, but not restricted to, office notes, laboratory results, and radiology findings. Additionally, I consent to the utilization of my image as an integral component of my medical record by the Bermuda Pain Relief Center.

Your medical records will only be shared with your General Practitioner, your referring Physician and any other health care provider of your preference.

Please advise us if you would prefer us to limit the sharing of your medical records.

FINANCIAL POLICY AND AGREEMENT

Bermuda Pain Relief Center is committed to providing you with the best in Pain Management Services. Our fees are based on current specialist pricing.

INSURANCE PAYMENTS

We encourage you to know your Schedule of Benefits based on your insurance policy. Your co-payment is due at the time of your visit and you are liable for any charges incurred as a result of services rendered, regardless of how your insurance provider pays for your claim.

CANCELLATION POLICY

We ask that you make your appointments carefully to ensure that you are able to keep them. After three no shows you will not be able to reschedule with Bermuda Pain Relief center. For cancellations with less than 24 hours notice you will be charged 50% of the consultation fee. If you arrive past your scheduled appointment time, you may be asked to reschedule.
I, First Name* Last Name* certify that I have read and understand the above information. I authorize and request my insurance company to pay my claim directly to the Bermuda Pain Relief Center. I understand that my health insurance provider may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.
I certify that I have read and understand the above information. I authorize and request my insurance company to pay my claim directly to the Bermuda Pain Relief Center. I understand that my health insurance provider may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.
Patient Signature*

Clear
Date*

MonthDayYear
Date
I would like to recieve periodic emails regarding services and procedures offered at the Bermuda Pain Relief Center

YesNo

NEW PATIENT FORM: PAIN

Patient information

DESCRIBE YOUR PAIN SYMPTOMS

MEDICATIONS AND ALLERGIES

Current pain medications:

Previous pain medications:

MEDICAL HISTORY

SOCIAL HISTORY

PSYCHOSOCIAL HISTORY