Your Preferred Date
Your Preferred Time
8AM - 6.30 PM only
Your Phone Number
Your Email ID
Address Line 1
Address Line 2
District of Columbia
Your Date of Birth
Person Responsible for Bill (Under 18)
Are you under 18 ?
Parent Mobile Number
Relationship to Patient
Emergency Contacts Name
Emergency Contacts Mobile Number
Relationship to Patient
Health Plan Information
Subscriber ID #
Does your insurance require a referral ? (If Yes, you must bring a copy with you to your appointment)
Present illnesses and Questionnaire
Your Height in cm
Current Pain Rating
0 - 10 ( 0 being the least and 10 being the highest )
Do you have any present illness ?
Please describe your symptoms, including any numbness, pain or weakness. ?
When did your symptoms begin and how have they progressed ?
Are they the result of an acute injury or accident ?
Which doctors have you seen for this problem ?
Which diagnostic studies have you had (MRI, X-Ray, CT Scan) ?
What has been your diagnosis ?
Which treatments have helped ?
Are you seeing an attorney for this problem ?
What makes your symptoms better or worse ?
Past Medical History
Do you have any medical history ?
Please list any current and past medical conditions or problems (i.e. Diabetes, High BR etc)
Have you had any surgeries or fractures ?
Please list all food and drug allergies :
Any Medications you use ?
Please list any important health issues with immediate family members :
Which activities are impaired by your symptoms ?
Review of Systems :
Taking Blood Thinners
High Blood Pressure
ENT, Lung , Heart , Kidney , Skin disorder
Loss of sensation around buttock and groin
Please select to any of the following conditions you might haye now or before.
What is your approximate daily use of tobacco?
I don't smoke
1/2 pack a day
1 pack per day
1-2 pack per day
More than 2 packs per day
Please Read the following before signing carefully
Signature ( Please Read the following before signing carefully )
Assignment Release and financial Agreement: I authorize treatment of the person named above and agree to pay all fees for such treatment. I hereby authorize my insurance benefits to be paid directly to the provider of service and I am financially responsible for non-covered services. I also authorize the physician to release any information to referring/consulting physicians or other health care providers as your physician deems appropriate to facilitate my care. I agree that I will not withhold or delay payment if my insurance company denies payment on any of my charges. I have also been informed of the $35.00 fee on checks returned. In the event it should become necessary to place for collection an unpaid balance due for services rendered to me or my family, I/we agree to pay interest, collection fees, and should legal action be filed, reasonable attorney fees, filing fees and any other costs.