NEW PATIENT REGISTRATION

CLINICAL PHARMACIST CONSULT FORM
Please Note this Intake form may take 1-2 hours to complete. *Please complete in one sitting*

This can be filled out by the patient or a care partner. This helps us better understand your current medical condition and how we can provide the best care to you.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender (Assigned at Birth)
If 'Other' Selected for Gender, please specify:
Are you Currently an Established Patient at Peak Neurology? (Select No if you have not had a visit with a Peak Neurology provider in the last year)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number (No dashes)
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
Spouse or Significant Other

First NameLast Name
Spouse/Significant Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACT
Name of Emergency Contact

First NameLast Name
Relationship of Emergency Contact
Emergency Contact Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Notification Preferences

List of Current/Recent providers
PCP Name (Primary Care Provider)
PCP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PCP Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
2) Other Provider Name and Specialty
2) Other Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2) Other Provider Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
3) Other Provider Name and Specialty
3) Other Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
3) Other Provider Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
4) Other Provider Name and Specialty
4) Other Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
4) Other Provider Fax Number
Please enter a valid phone number.Format: (000) 000-0000.

Peak Neurology Financial Policy: Self Pay
Name

First NameLast Name
Middle Initial
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
SSN (No dashes)
Self-Pay: Self-pay and previous balance amounts are due and payable at the time of service. Insurance co-payments are mandated by your insurance company and MUST be paid at each visit. Patients with insurance claims pending will be sent statements for the full amount due until the account is satisfied. I agree that if the insurance company denies benefits for any reason, I am responsible for the full amount owed for services provided.
Initial - I have read and agree to the above statement
Returned Checks: I understand and agree to pay a returned check charge of $35.00 for each check that is returned for any reason. I agree to pay the amount of the check plus the service charge within 30 days of receipt of notification.
Initial - I have read and agree to the above statement

Phone: 719-445-9902 or 719-212-0770

Fax: 719-387-0312

Email: admin@peakneurocos.com

www.peakneurocos.com
Acknowledgement of receiving Privacy Practices

I acknowledge that I have been offered to review and reviewed a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of the amended Notice of Privacy Practices will be available at each appointment if I request one.
Indicate relationship if not signed by patient
Patient Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Please complete below if refusing to sign the above acknowledgement
Patient Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Reason for refusal

Text appointment reminders
Patient Name

First NameLast Name
By signing you consent to receiving appointment reminders by text message and/or email.

You may choose to discontinue your participation in our digital communication any time by notifying the office by phone or email to stop further communication. Standard text/data rates may apply.
Signature (Must be 18 or older to sign, parent of minor)
Date

MonthDayYear
Date

Rows	YES	NO
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel full of energy?
4. Do you feel that your life is empty?
5. Are you in good spirits most of the time?
6. Do you often get bored?
7. Do you feel happy most of the time?
8. Do you prefer to stay at home, rather than going out and doing new things?
9. Do you think it is wonderful to be alive now?
10. Are you afraid that something bad is going to happen to you?
11. Do you often feel helpless?
12. Do you think that most people are better off than you are?
13. Do you feel you have more problems with memory than most?
14. Do you feel pretty worthless the way you are now?
15. Do you feel that your situation is hopeless?

CLINICAL PHARMACIST CONSULT FORM