Health History Initial

Health History Initial

  • Charges billed to the patient/guardian following insurance processing, may accrue interest in accordance with state law. This will not apply if payment arrangements are coordinated within 30 days. You will only receive a patient billing after all other options are exhausted. I understand that by consenting to treatment, I am authorizing the use of information provided to collect payment for medical services in accordance with state laws.
  • CHIEF ISSUE

  • SECOND ISSUE:

  • THIRD ISSUE:

  • REVIEW OF SYSTEMS

  • The following section is a review of all your systems. Have you been experiencing any of the listed symptoms for each section? If none are applicable please note "none" in each box below each section. If "Yes" note which ones in the box and describe (e.g. intensity; when began). Please feel free to add any other symptoms you've been experiencing to appropriate category.
 

Verification