New Patient Intake Forms

Patient Authorization for the Release of Medical Records
I, First Name Last Name , hereby authorize and direct the barer of any medical information on myself to release any and all medical records, in their entirety, to the physician or facility indicated below. This includes all medical records, in their entirety, to the physician or facility indicated below. This includes all information (including X-rays, ER records, ambulance reports, IME's, peer review records, hospital records, consultations, second opinions, etc) for any disease, disorder, mental or physical afflictions which I may have been treated for in the past, from the start of treatment to the present, in accordance with Chapter 397.017 and 455.211. Facsimile and/or electronic transmissions of records will be deemed acceptable, proving the records are complete and legible. In consideration of the above, I hereby release from responsibility for any liability arising from disclosure to the captioned holder of information, physician, or hospital.
Today's Date:*

MonthDayYear
Date
Patient Signature:*

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Patient Phone Number:*
Please enter a valid phone number.
Patient Identification:
Patient's Full Name:*

First NameLast Name
Patient's Date of Birth:*

MonthDayYear
Date
Social Security Number (SSN):*
ONLY last 4 digits
Date of Service:

MonthDayYear
Date the patient was seen or treated at another facility for treatment or surgery.
Florida Statutes: Chapter 395.017 Hospital Licensing and Registration. Chapter 455.241 Health Care Practitioner.

Any health care practitioner licensed pursuant to (Florida Statutes) who makes a physical or mental examination of, or administers treatment to any person, shall upon request of such person or their representative, furnish in a timely manner, without delay for legal reviews, copies of all such reports and records relating to such examination and treatment.
Holder of Information:
Physician or Hospital Name:
Physician or Hospital Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician or Hospital Phone Number:
Please enter a valid phone number.
Physician or Hospital Fax Number:
Please enter a valid fax number.
Please release information to the following doctor(s) at the address listed above:
- Dr. Bruce Kammerman, MD
- Carmen Lynch, DC
- Glenn Larsen, DC
- Gennea Williams, DC, ND
- Christopher Stenzel, DC
- Paul Kalloghlian, DC
- Alvaro "Varo" Betancourt, DC
- J. Reinaldo Heredia, DC
- Keegan Mente, DC
- Michael P. Newman, DC
Federal Injury Group

fitcofl@gmail.com

Phone: 727-600-8024

Fax: 727-600-8025
*For admin office use only: Licensed provider's signature:

Clear

Selection of Physician:
I,First Name Last Name , as of, Date*, choose Dr. Bruce Kammerman, MD, and a clinic of Federal Injury Group as my primary DOL doctor for my describe injury* injury which occurred on Date* .

Signature*
Patient Name:*

First NameLast Name
Please select a clinic of Federal Injury Group:*

Federal Injury Treatment Centers of FL: 2323 Curlew Road, Ste 2A, Dunedin, FL 34698Federal Injury Treatment Centers of USA: 3520 W HWY 326, Ocala, FL 34480Federal Injury Doctors: 2861 34th Street S., Floor 2, St. Petersburg, FL, 33711Federal Injury Mental Health: 2323 Curlew Road, Suite 2A, Dunedin, FL 34698DOL Doctors of Wesley Chapel: 6013 Wesley Grove Blvd, #105, Wesley Chapel, FL 33544Federal Injury Treatment Center of the Palm Beaches: 1625 S Congress Ave, Suite 190, Delray Beach, FL 33445Dr. Michael P. Newman, DC, PA: 9420 SW 77th Ave, Suite 100, Miami, FL 33156Federal Injury Treatment Center of North Palm Beach: 4414 Northlake Blvd, Palm Beach Gardens, FL 33410
- Dr. Bruce Kammerman, MD
- Carmen Lynch, DC
- Glenn Larsen, DC
- Gennea Williams, DC
- Christopher Stenzel, DC
- Paul Kalloghlian, DC
- Alvaro "Varo" Betancourt, DC
- J. Reinaldo Heredia, DC
- Keegan Mente, DC
- Michael P. Newman, DC
Federal Injury Group

fitcofl@gmail.com

Phone: 727-600-8024

Fax: 727-600-8025

In-Person/Telehealth Consent Form:

Health Care Services
1. I hereby authorize Health Care Services to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
Full Name:

First NameLast Name
Date*

MonthDayYear
Date
Signature:*

Clear

Upload Front & Back of Driver's License

Please upload a PNG, JPG or JPEG file. If you do not have a copy of your drivers license on your computer, please ensure to bring it to your first appointment and we will scan it into the computer for you.
Front of Driver's License Upload:

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Back of Driver's License Upload:

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Upload CA-1 or CA-2 Forms:
Which document will you be uploading?

CA-1: Traumatic, single shift injury. Ex. motor vehicle accident, broken bone, dog bite, etcCA-2: Occupational disease or injury that occurs over 2+ shifts. Ex. repetitive motion, etcI don't have either to upload.
Please upload a copy of your CA-1:

Cancelof
Please upload a copy of your CA-2:

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Should be Empty:

New Patient Intake Forms

DOL New Patient Information:

Medical Evaluation Questionnaire:

17. For the following questions, please do your best to rate your current pain on a scale from 0 (no pain) to 10 (excruciating pain):

Tasks: Please answer the following questions to the best of your ability.

Pain Disability Questionnaire:

Upper or Lower Limb Assessment:

Upper Limb Assessment:

Please use the scale below to rate the amount of difficulty for the following questions:

Please use the scale below to rate the severity of the following symptoms in the past week.

Please use the scale below to rate the severity of the following symptoms in the past week.

Lower Limb Assessment:

Please use the scale below to rate the your ability to do the following activities for the in the last week for the following questions:

Please use the scale below to rate the your pain in the last week for the following questions:

Patient Authorization for the Release of Medical Records

Patient Identification:

Holder of Information:

Selection of Physician:

In-Person/Telehealth Consent Form:

Upload Front & Back of Driver's License

Upload CA-1 or CA-2 Forms: