New Patient Form - Modernispine

Name

First

Last

Preferred Name

Street Address

City and State

Zip Code

Phone Number

or Name Member

Date of Birth (MM/DD/YYYY)

Email

Emergency Contact

(NAME, PHONE, RELATIONSHIP TO PATIENT)

Primary Insurance Name

Member ID / Policy Number

Group Number

Policy Holder Name

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

How did you find us?

Reason for visit

If this visit is related to a workplace or motor vehicle accident, please indicate the date of injury.

Images (XRAY, MRI, CT):

YES I have imaging regarding this concern.
NO prior imaging regarding this concern.
I am unsure

Imaging History (Please list facility, date, and type of imaging)

Current Medications: Name, Dose, Frequency (Prescription and Over-the-Counter)

Preferred Pharmacy (Name and Address)

Primary Care Provider (PCP): Name and Clinic

Allergies (Please list allergen and reaction)

Medication, Environmental, and Latex Allergies

I have no known medication, drug, or environmental allergies.
I have no known latex allergy.

MEDICAL HISTORY:

Family History (Please list family member and health condition)

Surgical History (Please list surgical procedures and year performed. Include 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

Please review these policies under the Patient Forms section.

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 AND OUTSTANDING BALANCES

I understand and agree that Moderni Spine PLLC requires payment of all balances, copays, and applicable fees at appointment check-in for services to be rendered. If I am unable to make payment when due, I understand that my appointment may be rescheduled until payment or outstanding balances are satisfied. For self-pay or cash-pay services not covered by insurance, a minimum payment of 50% is due at the initial visit.

PATIENT INFORMATION ACKNOWLEDGMENT

I acknowledge that the information provided is true and correct to the best of my knowledge. If I realize that I have omitted information or entered information incorrectly, I will notify Moderni Spine and my provider immediately. I understand that providing inaccurate or incomplete information may jeopardize my health, treatment, or insurance coverage for services.

Signature (Typing my name below serves as my electronic signature.)

Date

Legal Guardian or Authorized Representative Information

If the signature is provided by a legal guardian or authorized representative and not the patient, please complete the section below.

Authority Type

Parent
Legal Guardian
Power of Attorney
Other

Electronic Signature / Date

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