BPRC NEW PHYSIO PATIENT FORM

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*

First NameLast Name

Date of birth*

Date

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Home phone

Mobile phone *

Work phone

Emergency Contact Number*

Name of Employer

Insurance Company*

Certificate

Policy

Type of Health Insurance Coverage

Basic Plan (Hospital Coverage only)Major Medical PlanElite Medical Plan

Referring Physician

General Practitioner

Other physicians involved in your care

Where is your pain*

NEW PATIENT FORM: PHYSIO

FINANCIAL POLICY AND AGREEMENT