Patient Medical History & Cancellation Acknowledgement First Name *Last Name *Street Address *Apartment, suite, etcCity *State/Province *Postal Code *Date of Birth *Phone *CellWorkEmergency Contact Name *Emergency Contact Number *Has there been any changed in your general health in the last year? If yes, please explain; *YesNoUnsureIf yes, please explainAre you taking any medications, non-prescription drugs or herbal supplements of any kind? *YesNoUnsureIf yes, please listDo you have any allergies? (List Below) Medications: Latex/Rubber products Other: (Foods, Hay fever)Have you ever had an adverse reaction to any medication or injections? *YesNoUnsureIf yes, please listDo you have asthma? *YesNoUnsureIf yes, which inhaler do you use?Do you have or have you ever had any heart or blood pressure problems? *YesNoUnsureIf yes, please listDo you have or have you ever had a replacement/repair of a heart valve, an infection of the heart, or a heart condition from birth? *YesNoUnsureHave you ever had Hepatitis, Jaundice or liver disease? Which Hepatitis? *YesNoUnsureIf yes, which Hepatitis?Do you have a prosthetic or artificial joint? *YesNoIf yes, please explainDo you have bleeding problems or a bleeding disorder? *YesNoUnsureIf yes, please explainHave you ever been hospitalized for any illness or operations?Do you have any conditions or therapies that could affect your immune system (Leukemia, AIDS infections, Chemotherapy)? If yes, please explain; *YesNoUnsureIf yes, please explainDo you have any of the following?Emphysema EpilepsySeizuresFibromyalgiaThyroid DisorderHead/Neck InjuryKidney DiseaseLung DiseaseLupusMigraineOsteoporosisMedications (e.g. Fosamax, Actonel)PacemakerHigh/Low Blood PressureDiabetes Type 1 Diabetes Type 2 Drug /Alcohol DependencyTypeHypo/HyperglycemiaRadiation/ChemotherapyRheumatic FeverSexually/ Transmitted InfectionCold SoresAlzheimersAnginaAnemiaArthritisBlood TransfusionCancerChest PainEmphysemaHeart MurmurHodgkins DiseaseParkinsons DiseaseStomach UlcersThrustTmjTuberculosisNone of the aboveAre there any conditions or diseases not listed above that you have or have had?If yes, please explainAre there any medical problems that run in your family? (cancer, diabetes, etc) *YesNoUnsureIf yes, please explainDo you smoke or chew tobacco products? *YesNoOccasionallyAre you pregnant? *YesNoSignature *Start signing your signature hereYour browser does not support e-Signature field.The information I have given above is true to the best of my knowledge.Date *Cancellation Policy/No Show Policy *We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel, and we are unable to schedule you for a visit, due to a seemingly "full" schedule. We ask that patients give at least a 48-hour notice to cancel a reserved appointment. If an appointment is not canceled at least 48 hours in advance. 1. The first time there will be no charge. 2. Second time you may be charged a fifty-dollar ($50) no-show fee; this will not be covered by your insurance company. 3. If appointments are continued to be missed, you may receive a letter of dismissal from our office. We understand that delays can happen however we must try to keep the other patients and doctors on time. If you are aware you may be late for an appointment, please call ahead to let us know. If you are more than 15 minutes past your scheduled time, we may have to reschedule your appointment. Account Balance/ Insurance Policy Patients are responsible for understanding and maintaining their insurance coverage. As a courtesy, our office will do our best to gather as much information about your policy to ensure you will be covered. However, you as the patient are still responsible for any balance owing if the insurance fails to cover the treatment. We require any balance from treatment paid on the day of the appointment. We will require that patients with balances do pay their account balances to zero ($0) prior to receiving further services by our practice. If you have questions about your bills or you would like to discuss a payment plan option, you may call or come into the office to speak to our team to help review your account and concerns. By signing you agree to have read the following terms as listed above and agree to adhere by them.First Name *Last NameSignatureStart signing your signature here *Sign hereYour browser does not support e-Signature field.Date *Submit
