New Patient Form - Modernispine

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Let Pain Care be Self Care!

Phone Number

+1 651.440.0939

E-mail

cynthia@modernispine.com

Location

3454 County Rd 101 Minnetonka, MN 55345

Home
Conditions

Arm and Leg pain

Arthritis

Cervical & Thoracic Radiculopathy

Complex Regional Pain Syndrome (CRPS)

Compression Fractures

Degenerative Disc Disease

Diabetic Peripheral Neuropathy

Facet Joint Syndrome

Failed Back Surgery Syndrome

Herniated Disc

Joint Pain

Migraines

Pelvic Pain

Peripheral Neuropathy

Piriformis Syndrome

Post-Surgical Pain

Sacroiliac Joint Pain

Sciatica (Lumbar Radiculopathy)

Spinal Stenosis

Spondylolisthesis

Tension Headaches (Cervicogenic Headaches)

Vertebrogenic Pain

Whiplash Injury
Treatment

Botox Injections for Migraines, Jaw, and Neck Pain

CBD and Supplement Management

Epidural Steroid Injections

Hijama Therapy (Wet Cupping)

Hip Bursa Injections

Intracept Procedure (Basivertebral Nerve Ablation)

Low Level Laser Therapy (Cold Laser)

Trigger Point Injections

Medial Branch Blocks

Medial Branch Radiofrequency Ablation

Medical Cannabis Certification

MILD Procedure (Minimally Invasive Lumbar Decompression)

Occipital Nerve Blocks

Opioid & Non-Opioid Therapies

Peripheral Nerve Stimulation

Vertebroplasty/Kyphoplasty

Surgical Intervention Consultation

PRP (Platelet-Rich Plasma) Injections

Red & Infrared Light Therapy

Sacroiliac Joint Injections

Selective Nerve Root Blocks

Shockwave Therapy (ESWT)

Sphenopalatine Ganglion Blocks

Spinal Cord Stimulator

Supraorbital Nerve Blocks

Suprascapular Nerve Blocks
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- Why Refer to Moderni
- Refer a Patient

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New Patient Form

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Name *

First

Last

Preferred Name

Date of Birth (M/D/YYYY) *

HOW DID YOU FIND US?

Google
Referred by provider
Social Media
Signage/building
Lake Minnetonka Magazine
Other

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/State/Zip:

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

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:

I have no history of the following medical conditions
HIGH BLOOD PRESSURE
COPD/EMPHYSEMA
ASTHMA
DIABETES TYPE I/II
AUTOIMMUNE DISEASE
HEART DISEASE
OSTEOARTHRITIS
OSTEOPOROSIS
RHEUMATOID ARTHRITIS
BLEEDING/BLOOD DISORDER
CANCER
THYROID DISEASE
HEART ATTACK/MI/CORONARY BYPASS/HEART SURGERY
ABNORMAL HEART RHTHYM (I.E ATRIAL FIBRILLATION, WPW)
KIDNEY DISEASE
PSYCHOLOGICAL DISEASE (ANXIETY, DEPRESSION, BIPOLAR)
SEIZURE DISORDER
PARKINSONS
MEMORY LOSS/DISEASE
SLEEP APNEA
ANEMIA
EYE DISEASE (INCLUDING GLAUCOMA)
GASTROINTESTINAL DISEASE (IBS, CHRON’S, ULCERATIVE COLITIS, OTHER)
OTHER MEDICAL CONDITION NOT LISTED

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)

I do not and have not used tobacco
Smoker (current)
Smoker (Previous, been greater than 5 years)
Chewing tobacco
Vaping/Electronic Tobacco

Other Social history : (check all that apply)

I drink alcoho
I use illicit drugs
I use legal THC products
None

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)

CONSENTS & PRIVACY

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 *

Date

procedures WERE HISTORY:

FULL NAME:

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

LEGAL RELATIONSHIP TO PATIENT:

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

Our Memberships and liscensing

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At Modern Spine, we diagnose and treat spinal disorders, chronic pain, and musculoskeletal conditions to help you feel your best.

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Office

3454 County Rd 101 Minnetonka, MN 55345 (Second Level)

cynthia@modernispine.com
+1 651 440 0939

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