Health Quest
7920 McDonogh Road
Suite 101
Owings Mills, MD 21117
(410) 356-9939

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

Separate details with "," comma as shown above.



Separate details with "," comma as shown above.

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Family Health History


Separate details with "," comma as shown above.

(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

I certify that I am the patient or (legal guardian of the patient) listed on this form 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 by Health Quest Chiropractic & Physical Therapy, LLC (Health Quest). I 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, CONSENT TO TREAT: I authorize the licensed doctors at Health Quest and their staff to examine and treat my condition (or the condition of the minor child named above, for whom I am legally responsible), including the performance of chiropractic adjustments and/or other chiropractic, physical therapy and diagnostic procedures, as the doctors see fit. CONSENT TO RELEASE INFORMATION: I authorize Health Quest 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 this signed statement of authorization with my signature for required insurance submissions. I also authorize any company involved with any aspect of my claim to disclose any information to Health Quest necessary for determining the appropriate status of the processing of my claim. FINANCIAL RESPONSIBILITY: I fully understand that I am responsible for the full balance of any charges not paid by my attorney, settlement and/or insurance carrier. All bills shall be paid promptly in the usual manner, including but not limited to any PIP, Med-Pay or Med-Expense payments. I understand and agree that health/accident insurance policies are an arrangement between an attorney and/or insurance carrier and me. I understand that fees for services rendered by Health Quest will become immediately due upon suspension or termination of my care or treatment at Health Quest. I hereby irrevocably assign to Health Quest and direct said attorneys and/or insurance carriers to pay all reasonable fees for services provided by Health Quest from the proceeds of any recovery in my case and to pay those fees directly to Health Quest.FINANCIAL POLICY: I understand a finance charge of 30% will be assessed to my account if collections services are required for a delinquent balance. 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.SCHEDULING POLICY: I understand it is my responsibility to notify Health Quest 24 hours in advance if I am unable to make my scheduled appointment or I may be assessed a $50 fee. 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.I HAVE READ (OR HAVE HAD READ TO ME) THE ABOVE AGREEMENT. I have also had the opportunity to ask questions about its content, and by signing below, I agree to the aforementioned terms. I intend this AGREEMENT to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

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

Signature


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