Health Quest Chiropractic & Physical Therapy
7920 McDonogh Road, Suite 101
Owings Mills, MD 21117
410.356.9939
www.HQChiro.com

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

How did you find out about our office?


Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History


Family/Primary Physician

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Family Health History


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

Social History & Life Choices:


 

Health Problems & Concerns:


Please select all that you have had or currently have.

Authorization

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI understand and have been provided with a Notice of Privacy Practices (on our website) that provides a more complete description of information uses and disclosures, AUTHORIZATION FOR RELEASE OF RECORDSI hereby authorize Health Quest Chiropractic & Physical Therapy, LLC (Health Quest) to furnish my attorney and/or insurance carrier with any and all medical information, bills and/or records necessary for payment of services rendered to me or my dependent(s) at Health Quest. I also authorize any company that is in any way involved with any aspect of my claim to disclose any and all aspects of my claim to Health Quest so that appropriate status may be determined in the processing of my diagnosis, treatment and/or claim. ASSIGNMENT OF BENEFITS/DOCTOR’S LIENI understand that health and accident policies are an arrangement between my attorney and/or insurance carrier and myself. Furthermore, I understand Health Quest will assist me in submitting claims to my attorney and/or insurance company. I hereby irrevocably assign to Health Quest Chiropractic & Physical Therapy, LLC and direct said attorneys to pay from the proceeds of any recovery in my case all reasonable fees for services provided by Health Quest, including fees for preparation and testimony, as a result of my injury or condition. Payment is to be made directly to: Health Quest Chiropractic & Physical Therapy, LLC; 7920 McDonogh Road, Suite 101; Owings Mills, MD 21117FINANCIAL POLICYI understand full payment of health insurance copays, estimated coinsurance, deductibles and/or services not covered by another party is due at the time of service. If my insurance plan requires a referral, I am responsible for bringing the referral prior to treatment. If I fail to provide a proper referral, I will be required to pay for my visit as if I was non-insured. I also understand it is my responsibility to notify Health Quest in writing of any changes in my personal information and/or changes of insurance information. I agree that all unpaid invoices accrue interest at the rate of 6% per annum from the date of invoice, if any outstanding balance is not paid in full within thirty (30) days of the invoice date. I agree that should I not pay my balance in full, and Health Quest hires an attorney to pursue collection, that I am responsible for all litigation costs incurred by Health Quest, including reasonable attorney’s fees in the amount of no less than 15% of the principal balance due and owing. I further agree that the Statute of Limitations applicable to any civil claim Health Quest may bring with respect to any claim for services mentioned above will not begin to run until I send a denial, in writing, of any outstanding balance. Said written denial must be mailed certified mail, return receipt requested, and said return receipt will be required to show proof of the notice of this denial. I understand that Health Quest does not waive its rights under this Paragraph if not immediately enforced.I understand it is my responsibility to notify Health Quest 24 hours in advance if I am unable to make my scheduled appointment. There will be a $25 fee assessed to my account if I fail to do so. I understand all overpayments more than $10.00 will be automatically refunded to me once all outstanding claims have been processed by my insurance. Overpayments under $10 will remain credited to my account for future use unless I request a reimbursement.

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

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