• Video EMC

    New Patient Forms
  • Patient Information

    This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching a diagnosis. This form relies on the accurate information you provide.
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    Pick a Date
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  • Insurance Information

    If you are unsure of claim #, please put a 0 to be able to submit form. However, please note a claim # is needed to bill your auto insurance for our services.
  • Attorney Information

    If you do not have an attorney please put N/A or none to be able to submit form.
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  • Accident Information



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  • Current Health Issues

  • Authorizations and Agreements

    Please read and agree to each section below
  • Office of Insurance Regulations

    Click/tap on the blue box area on the form and type in your name as an electronic signature.
  • The form below (OIR-B1-1571) utilizes your ELECTRONIC SIGNATURE.  In the blue highlighted fields provided, you will type your name twice, once in the "Print Name" field and again in the "SIGNATURE FIELD", followed by the date.  

  • SIGNATURE

  • Clear
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    Pick a Date
  • Should be Empty:
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