New Patient Form - Modernispine

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LET PAIN CARE BE SELF CARE!

Moderni Clinic

651.440.0939

cynthia@modernispine.com

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New Patient Form

Before completing your registration, please review the following Moderni Clinic Policies.

–Consent to Treat Policy

–Financial Policy

–Notice of Privacy Practices

New Patient Forms

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Name *

First

Last

Preferred Name

Street Address *

City and State *

Zip Code *

Authorized Information list

Phone Number *

Date of Birth (MM/DD/YYYY) *

Email *

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

Emergency Contact

(NAME, PHONE, RELATIONSHIP TO PATIENT)

Primary Insurance Name (If no insurance type self pay) *

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?

Google
Referred by provider
Social Media
Signage/building
Other

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: *

None
High Blood Pressure
Heart Disease / Stroke
Heart Attack / Coronary artery disease
Diabetes
Thyroid Disease
Asthma
Sleep Apnea
COPD / Emphysema
Arthritis / Joint Disease
Chronic back and neck pain
Rheumatoid Arthritis
Autoimmune Disease
Bleeding disorder / Blood Clots
On blood thinners
Arrhythmia / Atrial fibrillation
Neuropathy / Nerve disorder
Seizures
Anxiety / Depression
Kidney or liver disease
Gastrointestinal disease (IBS, GERD, ETC)
Cancer (type_____________________)
Pacemaker / Implanted device
Recent surgery (within 12 months)
Pregnant or trying to conceive
Other: ____________________________

Family History (Please list family member and health condition)

Surgical History (Please list surgical procedures and year performed. Include surgeon if known.)

Other Social history : (check all that apply)

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

MODERNI CLINIC POLICIES: *

I have read and agree to the Moderni Clinic Consent to Treat Policy, Financial Policy, and Notice of Privacy Practices.

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 *

Professional Memberships & Licensure

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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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