Elite New Patient Intake Form Logo
Language
  • English (US)
  • Spanish (Latin America)
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  • PATIENT INFORMATION

  • CHIEF COMPLAINT(S)

  • SELECT ANY ADDITIONAL AREAS OF PAIN OR WEAKNESS

  • SYMPTOM ORDER

    List your problems from most to least concerning:

  • PROVIDERS OR CLINICS YOU'VE SEEN

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  • Patient's Medical History

  • SOCIAL / LIFESTYLE / OCCUPATIONAL FACTORS

  • Date of last period:   Pick a Date   

  •  HIPAA Authorization for the Release of Protected Health Information (PHI)

  • Full Name:         

    Date of Birth:   Pick a Date   

    Phone Number:         

  • Authorization

    I hereby authorize Elite Medical Center, LLC, to use or disclose my individually identifiable health information as described below.

  • Patient Rights and Acknowledgment

    • I understand that I have the right to revoke this authorization at any time by submitting a written request to the provider’s office.
    • I understand that revocation will not apply to information already released in reliance on this authorization.
    • I understand that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected under federal HIPAA privacy regulations.
    • I understand that I am not required to sign this authorization in order to receive treatment.

  • Expiration Date:      
    This authorization will expire on   Pick a Date   
    (If left blank, this authorization will expire one year from the date of signature.)

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  • Phone Communication & Messages


    I give permission for Elite Medical Center, LLC to leave messages regarding my medical care, including appointment reminders, billing, and treatment information:

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    Name: Relationship:                 

  • Should be Empty: