Desir Medical
Personal Information
Name
First Name
Last Name
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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12
13
14
15
16
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18
19
20
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24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
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1991
1990
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1936
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sex
Please Select
Male
Female
N/A
Contact Number:
Format: (000) 000-0000.
E-mail
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Please Select
Single
Married
Divorced
Legally separated
Widowed
Emergency Contact:
First Name
Last Name
Relationship
Contact Number
Format: (000) 000-0000.
Your Employer
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please check all that apply?
New Patient
Established Patient
Change in Insurance
No Insurance
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Medical Information
Weight (pounds)
Height (inches)
Reason for your visit
Please check to what area of your body your diagnosis/problem is related:
Please Select
Neck
Shoulder
Back
Elbow
Hip
Knee
Ankle
Foot
Leg
Stomach
Chest
Pelvis
Not listed
Why are you requesting an initial visit?
Have you been experiencing any abnormal symptoms?
Yes
No
Please describe.
Do you smoke?
Never
Rarely
Sometimes
Often
How many packs a day?
Not more than one a day
1-3 cigarettes a day
3-5 cigarettes a day
A pack or more a day
Do you drink alcohol?
Never
Rarely
Sometimes
Often
How many 8 oz glasses you have weekly?
One - Two glasses a week
Two - Four glasses a week
Four -Six glasses a week
Do you have any food allergies?
Yes
No
Please list your food allergies.
Medication
Are you allergic to any medication?
Yes
No
What medication?
Are you currently taking any medications?
Yes
No
1. What is the name of the medication?
What is the medication dosage?
*
How often do you take this medication?
*
Is the date on your prescription within the last 30 days?
*
Yes
No
Are you taking any other medications?
*
Yes
No
2. What is the name of the medication?
*
2. What is the medication dosage?
*
2. How often do you take this medication?
*
2. Is the date on your prescription within the last 30 days?
*
Yes
No
2. Are you taking any other medications?
*
Yes
No
3. What is the name of the medication?
*
3. What is the medication dosage?
*
3. How often do you take this medication?
*
3. Is the date on your prescription within the last 30 days?
*
Yes
No
3. Are you taking any other medications?
*
Yes
No
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Insurance Information
No Insurance
Primary Insurance Policy Holder
Primary Insurance Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Primary Insurance Policy Holder's Address
Primary Insurance Policy Holder's Employer.
Primary Insurance Policy Holder's Employer State and Zip Code
Primary Insurance
Primary Insurance Policy Number/Member ID
*
Primary Insurance Group Number
*
Do you want to add another insurance?
Yes
No
Secondary Insurance
Secondary Insurance Policy Holder
Secondary Insurance Policy Holder's Birthday
-
Month
-
Day
Year
Date
Secondary Insurance Policy Holder's Address
Secondary Insurance Policy Holder's Employer
Secondary Insurance Policy Holder's Employer State and Zip Code
Secondary Insurance Policy Number/Member ID
*
Secondary Insurance Group Number
*
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Adrian Health and Wellness Disclaimer
THE PRACTITIONERS AT ADRIAN HEALTH AND WELLNESS ARE INDEPENDENT OF EACH OTHER IN THEIR PRACTICE OR PROFESSIONAL SERVICE. CLAIMS, EITHER IMPLIED OR EXPRESSED, AGAINST THE CLINIC OR THE PRACTIONERS WILL NOT BE ADDRESSED OTHER THAN THOSE BETWEEN THE PATIENT AND HIS/HER PROVIDER. I CONSENT TO FULL RESPONSIBILITY FOR PAYMENT OF THESE SERVICES AND AGREE TO PAY THEM IN FULL AT THE TIME OF SERVICE, UNLESS OTHER ARANGEMNTS HAVE BEEN MADE WITH MY INSURANCE OR PROVIDER. I ALSO CONSENT TO FULL RESPONSIBILITY FOR PAYMENT OF MISSED APPOINTMENTS WHEN NO NOTICE OF CANCELLATION IS MADE 24 HOURS IN ADVANCE. I ALSO CONSENT TO PAYMENT FOR A FEE OF $50 IF COLLECTION ACTION IS NECESSARY TO COLLECT ON ANY UNPAID BALANCES ON MY ACCOUNT.
*
I agree to the Terms and Conditions.
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Authorization Form
I authorize use of this form on all my insurance submissions.
*
Yes
I authorize release of information to Adrian Health and Wellness.
*
Yes
I authorize Adrian Health and Wellness to obtain information from my insurance company(s).
*
Yes
I authorize Adrian Health and Wellness to act as my agent in obtaining payment from my insurance company(s).
*
Yes
I authorize direct payment to Adrian Health and Wellness.
*
Yes
I permit a copy of this authorization to be used in place of the original.
*
Yes
Do you authorize release of information to Adrian Health and Wellness including but not limited to your primary Care Physician?
*
Yes
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Health Insurance Portability & Accountability Act (HIPPA) Privacy Acknowledgment Form
I have received a copy of the Adrian Health and Wellness Clinic treatment and diagnosis privacy notice. I understand that the privacy notice contains information that will help me get any questions I have answered regarding my privacy and provides me with the information to file a complaint related to the use of my protected health information.
I agree to the use of my protected health information.
Signature
Payment Responsibility
IT IS YOUR RESPONSIBILITY TO KNOW YOUR INDIVIDUAL INSURANCE POLICY. MANY INSURANCE POLICIES HAVE EXCLUSIONS. MOST HAVE DEDUCTIBLES, CO-PAYMENTS AND CO-INSURANCE. SOME INSURANCE POLICIES MAY NOT COVER OUR SERVICES. IT IS IMPORTANT FOR YOU TO CHECK WITH YOUR INSURANCE CARRIER TO DETERMINE IF THE PROVIDER YOU ARE SEEING IS LISTED AS AN "IN-NETWORK" PROVIDER. IF THEY ARE NOT LISTED AS AN 'IN-NETWORK" PROVIDER YOU MAY HAVE A HIGHER DEDUCTIBLE AND/OR CO-PAY.REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR ALL BILLS NOT COVERED BY YOUR INSURANCE POLICY.
I understand I am responsible for all bill not covered by my insurance policy.
Signature
Private Payment Information
For patients not utilizing insurance, usual and customary fees of Adrian Counseling and Psychiatric Clinic apply unless a different rate is listed below.
I HAVE READ, UNDERSTAND AND AGREE WITH THE FINANCIAL CONDITIONS DESCRIBED ABOVE.
Signature
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