BioLogics New Patient Form

INSURANCE INFORMATION

Who is responsible for this account?______________

Relationship to patient:_________________________

Group# (Plan, Local, or Policy#):_________________

Is patient covered by additional insurance? Yes No

Subscriber's Name:____________________________

Birthdate:_______________ SS#:________________

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent)
have insurance coverage with___________________
and assign directly to Dr._______________________
all insurance benefits, if any, otherwise payable to me
for services rendered. I understand that I am finan-
cially responsilble for all charges whether or not paid
by insurance. I hereby authroize the doctor to release
all information necessary to secure the payment of
benefits. I authorize the use of this signature on all
insurance submissions.

___________________________________________
Responsible party signature

___________________________________________
Relationship and Date signed




						Print this form, fill it in and fax to 714.841.2564. Call to make an appointment for a free consultation and assessment. Today's Date__________________
	PATIENT INFORMATION Name:_____________________________________ Home Address:______________________________ City:___________________ ST:____ ZIP:________ Home Phone#:______________________________ Cell Phone #:_______________________________ Sex: Male Female Birthdate:________________ Age:___________ Social Security #:____________________________ Referred by:________________________________ SPOUSE Name:_____________________________________ Birthdate:______________ SS#:_______________ Employer Name:_____________________________ Occupation:_________________________________ Address:___________________________________ City:________________ ST:________ ZIP:_______ Phone #:___________________________________					INSURANCE INFORMATION Who is responsible for this account?______________ Relationship to patient:_________________________ Group# (Plan, Local, or Policy#):_________________ Is patient covered by additional insurance? Yes No Subscriber's Name:____________________________ Birthdate:_______________ SS#:________________ ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with___________________ and assign directly to Dr._______________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am finan- cially responsilble for all charges whether or not paid by insurance. I hereby authroize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. ___________________________________________ Responsible party signature ___________________________________________ Relationship and Date signed
	IN CASE OF EMERGENCY, CONTACT: Name:__________________________________ Relationship:________________________________________ Home Phone:_______________________________ Work Phone:_____________________________________
	EMPLOYER Company Name:_____________________________ Occupation:_________________________________ Address:___________________________________ City:__________________ ST:_____ ZIP:________ Phone:_____________________________________					ACCIDENT INFORMATION Is condition due to an accident? Yes or No Date of accident:_____________________________ Type of accident: Auto Work Home Other To whom have you made a report of your accident? Auto Insurance Employer Workers Comp Other Attorney Name (if applicable)_____________________
	PATIENT CONDITION Reason for visit (please circle): work sports auto trauma chronic What happened?_____________________________________________________________________________ When did your symptons begin?_________________________________________________________________ Is this condition getting worse? (please circle) Yes No Constant Comes and goes Please describe the pain and its location:_________________________________________________________ Is this condition interfering with your (please circle): work, sleep or daily routine Have you had this or similar conditions in the past? (please circle) Yes No If so, please explain:_________________________________________________________________________ HEALTH HISTORY Are you pregnant? Yes No Are you taking any of the following medications? (please circle all that apply) Nerve Pills Pain Killers (including aspirin) Muscle relaxers Stimulants Blood thinners Tranquilizers Insulin Other(s)___________________________ Do you eat, drink, or use? (please circle all that apply) Alcohol Carbonated beverages Chew Tobacco Cigarettes Coffee Please list any other serious medical conditions(s) you have or ever had:________________________________ __________________________________________________________________________________________ Please list anything that you may be allergic to:____________________________________________________ List previous surgeries/treatments with dates:_____________________________________________________ List any serious accidents with dates:____________________________________________________________ Do you smoke (please circle): Yes No How much?_________________ How long?______________ Are you wearing (please circle): Heel lifts Sole lifts Inner soles Arch supports
	SHOW US WHERE IT HURTS Please mark area(s) of injury of discomfort as shown below in the example. Indicate the degree of pain using a scale of 1 (discomfort) to 10 (extreme pain).

	Guarantee: If we accept you as a patient, we fully expect you to obtain results. In fact, we guarantee results! If you do not receive results within five visits, or if for any reason you are not pleased with your treatment, we will give you a full refund. . . no questions asked, no catches, no gimmicks. I am interested in the guarantee: (circle one) Yes No

PATIENT INFORMATION

SPOUSE

INSURANCE INFORMATION

IN CASE OF EMERGENCY, CONTACT:

EMPLOYER

ACCIDENT INFORMATION

PATIENT CONDITION

HEALTH HISTORY

SHOW US WHERE IT HURTS