New Patient Intake Form - LV Pain Center (TESTING - NOT ACTIVE)

Please use the online form for LV Pain Center
* = Required Information

PATIENT INFORMATION
Name Name * First Last
Date of Birth: Date of Birth: * / MM / DD YYYY
Age *
Must be between 1 and 3 digits. Currently Entered: 0 digits.
Sex *

Sex Male Female Intersex Prefer not to say Another term (please specify) Another term (please specify)
Marital Status
Primary Phone # Primary Phone # * - ### - ### ####
Work Phone # Work Phone # - ### - ### ####
Secondary Phone # Secondary Phone # - ### - ### ####
Best time to call? *
Email *
Employment *

Employment Full Time Part Time Retired Student None
Employer *
How did you hear about us? *
Referring Physician Name
Primary Care Physician
How did you hear about us?
(Other)
EMERGENCY CONTACT INFORMATION
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Cell Phone # Emergency Contact Cell Phone # - ### - ### ####
Emergency Contact Home Phone # Emergency Contact Home Phone # - ### - ### ####
Relationship
INSURANCE INFORMATION
Payment Options *

Payment Options Self-pay patient / Health Insurance Attorney lien
Do you have health insurance? *

Do you have health insurance? Yes No
Attach a picture of your Drivers License / ID Card:
Upload a File

Attach Files
Attach a picture of your Health Insurance Card:
(Front Of Card)
Upload a File

Attach Files
Attach a picture of your Health Insurance Card:
(Back Of Card)
Upload a File

Attach Files
Primary Insurance
Copay
Certificate#/Policy ID
Group Number
Subscriber Name
Subscriber DOB Subscriber DOB / MM / DD YYYY
Relationship to Subscriber
Please choose the best option listed that describes your race. *
Race
(Other)
Please choose the best option listed that describes your ethnicity.
Primary Language
Please mark the correct box if the question applies to you, and select the score based upon your gender. If not applicable, please choose N/A.
1. Has anyone in your family ever had a history of substance abuse? *

1. Has anyone in your family ever had a history of substance abuse? Alcohol Illegal Drugs Prescription Drugs N/A
F Score
(Alcohol)

F Score
(Alcohol) 1 2 4
F Score
(Illegal Drugs)

F Score
(Illegal Drugs) 1 2 4
F Score
(Prescription Drugs)

F Score
(Prescription Drugs) 1 2 4
M Score
(Alcohol)

M Score
(Alcohol) 3 3 4
M Score
(Illegal Drugs)

M Score
(Illegal Drugs) 3 3 4
M Score
(Prescription Drugs)

M Score
(Prescription Drugs) 3 3 4
2. Have you ever had a personal history of substance abuse? *

2. Have you ever had a personal history of substance abuse? Alcohol Illegal Drugs Prescription Drugs N/A
F Score - Personal
(Alcohol)

F Score - Personal
(Alcohol) 3 4 5
F Score - Personal
(Illegal Drugs)

F Score - Personal
(Illegal Drugs) 3 4 5
F Score - Personal
(Prescription Drugs)

F Score - Personal
(Prescription Drugs) 3 4 5
M Score - Personal
(Alcohol)

M Score - Personal
(Alcohol) 3 4 5
M Score - Personal
(Illegal Drugs)

M Score - Personal
(Illegal Drugs) 3 4 5
M Score - Personal
(Prescription Drugs)

M Score - Personal
(Prescription Drugs) 3 4 5
3. Mark box if your age is between 16-45 *

3. Mark box if your age is between 16-45 Yes, I am between 16-45 N/A
F Score 16-45

F Score 16-45 1
M Score 16-45

M Score 16-45 1
4. Have you had a history of preadolescent Sexual Abuse? *

4. Have you had a history of preadolescent Sexual Abuse? Yes, I have had a history of preadolescent Sexual Abuse N/A
F Score
(Preadolescent Sexual Abuse?)

F Score
(Preadolescent Sexual Abuse?) 3
M Score
(Preadolescent Sexual Abuse?)

M Score
(Preadolescent Sexual Abuse?) 0
5. Have you ever been diagnosed with Attention Deficit Disorder, Obsessive Compulsive Disorder, Bipolar, or Schizophrenia? *

5. Have you ever been diagnosed with Attention Deficit Disorder, Obsessive Compulsive Disorder, Bipolar, or Schizophrenia? Yes, I have been diagnosed N/A
F Score
(diagnosed)

F Score
(diagnosed) 2
M Score
(diagnosed)

M Score
(diagnosed) 2
6. Have you ever been diagnosed with Depression? *

6. Have you ever been diagnosed with Depression? Yes, I have been diagnosed with Depression N/A
F Score
(Diagnosed with Depression)

F Score
(Diagnosed with Depression) 1
M Score
(Diagnosed with Depression)

M Score
(Diagnosed with Depression) 1
Total
(Add up all checkboxes above) *
Date
(Auto Filled) Date
(Auto Filled) / MM / DD YYYY
Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to my provider when they accept assignment.
Authorization To Release Medical Information: I hereby authorize my Provider to release any information necessary for my course of treatment.
I certify that the above information is correct as of the date signed. *

Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to my provider when they accept assignment.
Authorization To Release Medical Information: I hereby authorize my Provider to release any information necessary for my course of treatment.
I certify that the above information is correct as of the date signed. YES
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

New Patient Intake Form - LV Pain Center (TESTING - NOT ACTIVE)

New Patient Intake Form - LV Pain Center (TESTING - NOT ACTIVE)

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

Please mark the correct box if the question applies to you, and select the score based upon your gender. If not applicable, please choose N/A.