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New Patient Information

Filling out this form in advance, with personal and insurance information, will speed the process when you first arrive.

 Patient Intake

Minimum required fields are indicated in red text, but please fill out the form as completely as possible. Please read the HIPAA privacy policy prior to submission. Your privacy is very important to us.


Patient's Name
Home Address
City
Zip
Home Phone
Cell Phone
DOB
SS#
Email
 
Who can we thank for referring you to our office?
      Age:
Marriage Status:
Divorced Married Widowed
 
Occupation
Employer Name
Employer Address
Employer Phone
 
Major Complaint
How Long?
 
Is this due to an injury?
Job Slip/Fall Other
 
Injury Date
Was the accident reported to anyone?
 
Have you seen anyone else for this condition?
Yes
When did you see the doctor for this condition?
Doctor's Name
Doctor Phone
 
General Practitioner
GP Phone
Is the condition getting worse?  
Yes
 
Rate the severity of your pain:
(1 least pain) to (10 severe pain)    
 
Type of pain of complaint:
Dull Burning Shooting Numbness
Throbbing Aching Cramps Stiffness
Other
How do your complaints interfere with your daily routine?
What treatment or self-help have you done for this complaint?
Did it help?
Permanently
Name and address of other doctors who have treated you for this condition.
Date of last Spinal X-ray?
Date of last MRI, CT Scan, Bone Scan?
Exercise:
Moderate Daily Heavy
Work Activity:
Light Labor Standing Sitting
 
Habits:
Alcohol/Drinks/week Caffeine High Stress Level
 
Injuries:(Falls, broken bones)
 
Surgeries:
 
Medications: What you take them for.
 
Vitamins and Minerals:
 
Select "Yes" or "No" to indicate if you had any of the following.

 Insurance Information

Health Insurance

Name of Insured
Relationship to you
Insurance Company
Insurance Phone
Policy Number
Group Number
ID/Member #
 

Auto Insurance

Your Insurance
Insurance Company
Claim #
Insurance Phone
Adjuster's Name
 
Other Party's Insurance
Insurance Company
Claim #
Insurance Phone
Adjuster's Name
 
 Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage with
and assign directly to Dr. Carmichael all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all insurance submissions.
 
Responsible Party Name
Responsible Party Relationship
By typing my initials in the box below, I certify that this will serve as a legal equivalent to my signature
Initials
 
I have read, and agree to, the HIPAA privacy policy
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         Conveniently Located        

WADSWORTH / EASTMAN
3214-B S. Wadsworth Blvd.
Lakewood, CO 80227 [map]
303-984-1700

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