New Patient Form

Name

First

Last

Preferred Name

Date of Birth (MM/DD/YYYY

HOW DID YOU FIND US?

Phone Number

Email

I consent to the following methods of contact from Moderni Spine PLLC. Check all that apply

Phone Call (Required)
Email – (Required for patient portal access)
Text
Mail

Street Address:

City and State

Zip Code

Reason for Visit

If this is related to a Workplace or Vehicle accident, what was the date of Injury?

Current Medications: Name, Dose, Frequency Over-the-counter & RX

PHARMACY (preferred pharmacy name & address)

Insurance Carrier

Policy Holder

known) (please as

Policy Number

Group

PRIMARY CARE PHYSICIAN OR PROVIDER:

CLINIC:

OTHER SPECIALIST: (name, specialty & location)

EMERGENCY CONTACT

(Name, Phone, Relationship)

ALLERGIES (please list ALLERGEN as well as REACTION)

I HAVE NO KNOWN MEDICATION/DRUG, ENVIRONMENTAL ALLERGIES
I HAVE NO LATEX ALLERGY

MEDICAL HISTORY:

FAMILY HISTORY: (Please list family member & history of health conditions)

SURGICAL HISTORY: (Please list any surgical procedures and year, please list surgeon if known)

TOBACCO USE: (please select one)

Other Social history : (check all that apply)

Alcohol use daily
Alcohol use occasional-rare
Illegal drug use
Legal THC product use

IMAGES (XR, MRI, CT):

YES, I have an image regarding this concern
No recent imaging (>3 years ago)
I am unsure

WHERE WERE THE IMAGES DONE: (Facility, date, type)

Consent & Privacy (Please review these policies under Patient>>Forms)

I agree to Moderni Spine PLLC Consent to Treat Policy
I Agree to Moderni Spine PLLC Financial Policy
I Agree to Moderni Spine PLLC Privacy Practices Policy

SELF PAY POLICY/OUTSTANDING BALANCE

I agree and understand that Moderni Spine PLLC requires balances, copays, and other payment at appointment check-in for services to be rendered. If I am unable to make payment a payment that is due, I do understand that my appointment may be rescheduled until I am able to pay for services or my outstanding balance. For Self/Cash-pay (non-insurance covered services) payment of at least 50% is due at initial visit.

I AKNOWLEDGE THIS INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. SHOULD I REALIZE I OMMITED INFORMATION OR MISTAKELY ENTERED INFORMATION I WILL INFORM MODERNI SPINE AND MY PROVIDER IMMEDIATELY. I UNDERSTAND MISINFORMATION ON THIS FORM COULD JEPORDIZE MY HEALTH, TREATMENT, OR INSURANCE COVERAGE OF SERVICES.

Signature (I acknowledge that typing my name below serves as my digital signature)

Date

GUARDIAN/MEDICAL AUTHORITY NAME

IF SIGNING ON BEHALF OF THE PATIENT PLEASE PRINT YOUR NAME HERE

LEGAL RELATIONSHIP TO PATIENT:

IF SIGNATURE IS BY LEGAL GUARDIAN/MEDICAL AUTHORITY AND NOT THE PATIENT, PLEASE COMPLETE BELOW: