Gold Coast Chiropractic
405 Main StSuite 4
Suite 4
Port Washington, NY 11050
516-944-4300

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information


Personal Information
Contact Information
Feet Inches
   
 

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)

   

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Personal Health History


Family/Primary Physician

Separate details with "," comma as shown above.



Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Personal Incident History:


If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History


Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Chiropractic Experience

Please select all that apply.

Other:

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:





Results:

Were You Aware That...

Health Problems & Concerns:


Please select all that you have had or currently have.

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

Authorization

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office, its staff and any fill in doctors to examine and treat my condition as the doctors see fit. If I am pregnant, plan on becoming pregnant or think I am pregnant I will notify the doctor. I will have or have had the opportunity to discuss the nature and purpose of the chiropractic treatments. I understand that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. It is not unreasonable to expect the doctor to be able to anticipate and explain all risks and complications of a given procedure on any particular visit and I wish to rely on the doctors to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. There is no promise, implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment in this clinic. By signing this document, I am consenting to treatment. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. I hereby authorize and direct any and all insurance carriers, attorneys, agencies, governmental departments, companies, individuals, and/or legal entities (“payers”), which may elect or be obligated to pay, provide, or distribute benefits to me for any medical conditions, accidents, injuries, or illnesses, past, present, or future (“condition”) to pay directly and exclusively in the name Ronny Bergman, DC PC (“office”) such sums as may be owing to Ronny Bergman, DC PC for charges incurred by me at the office relating to my condition (“charges”), with such payments to be made exclusively in the name of Ronny Bergman, DC PC. I further grant a lien to Ronny Bergman, DC PC with respect to my charges. This lien shall apply to all payers and to the full extent permitted by law. For the purposes of this document (herein, “Assignment and Lien”), “benefits” shall include, but not limit to, proceeds for any settlement, judgment, or verdict, as well as any proceeds relating to commercial health or group insurance, attorney retainer agreements, medical payment benefits, personal injury protection, no-fault coverage, uninsured and underinsured motorist coverage, third party liability distributions, disability benefits, worker’s compensation benefits, and any other benefits or proceeds payable to me for the purpose stated herein. In the event that I retain one or more attorneys to represent me in this matter, who are not located in New York, I will direct each attorney to issue a letter of protection to this office regarding my charges. Upon issuance, I hereby agree that such letter(s) of protection cannot be revoked or modified without the express written consent of this office. I authorize this office to release any information regarding my treatment or pertinent to my case to all payers as defined above to facilitate collection under this Assignment and Lien. I further authorize and direct all payers to release to Ronny Bergman, DC PC any information regarding any coverage or benefits which I may have including but not limited to, the amount of the coverage, the amount paid thus far, and the amount of any outstanding claims, I hereby direct this Office to file a copy of this Assignment and Lien, together and applicable charges, with any or all payers, regardless of whether a claim has been established with said payers. I hereby Ronny Bergman, DC PC, payment of an account relating to me, my spouse, or any of my dependents. I further authorize Ronny Bergman, DC PC to apply any credit balances on charges incurred by me to any other outstanding charges still owed by me, my spouse, or my dependents, regardless of whether or not these other charges are related to my condition. I understand that I remain personally responsible for the total amounts due to Ronny Bergman, DC PC for their services, even if the services are not deemed medically necessary and/or after a payment has already been issued and made to be returned due to a lack of medical necessity or over utilization. This Assignment and Lien does not constitute any consideration for this Office to await payments and it may demand payments from me immediately upon rendering services at its option. If this office must take an action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse Ronny Bergman, DC PC for all costs of such collection efforts, including, but not limited to, all court costs and all attorney fees. I am aware that Dr. Bergman is an out of network provider and I am aware that I may be financially responsible for services that are not covered by my insurance company, including deductibles, and or co-pays.This Assignment and Lien shall not be modified or revoked without the mutual written consent of Ronny Bergman, DC PC and myself. I hereby revoke any previously signed authorizations, whether executed at this office or any other office to the extent that the terms of those authorizations conflict with the terms of this Assignment and Lien.

Name of the Insured:
(Please Print)
_____________________________________________    
Patient's/Guardian's signature:
_____________________________________________
Date:
__________

Signature


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