New Patient Registration Master

New Patient Registration

First Name

Middle Name

Last Name

DOB

Phone

Confirm Email

Nickname

Preferred Contact Method(s)

Text Email Phone

Gender

Male Female

Emergency Contact

Relationship to Patient

Emergency Contact Phone

Consent for Treatment

I hereby voluntarily authorize the physicians, nurses, and healthcare providers at Vertex Spine to perform reasonable and necessary medical examinations, tests, and treatment for the condition that brought me to seek care. I understand that if additional testing, invasive procedures, or surgical interventions are recommended, I will be provided with further explanation and asked to sign specific consent forms prior to those procedures. By selecting "I Agree" below, you acknowledge and agree that you are signing this Consent for Treatment electronically. You agree that your electronic selection is the legal equivalent of your manual/physical signature on this document, meeting all criteria under the Federal ESIGN Act and state law. You consent to be legally bound by this agreement's terms and conditions.

Electronic Signature Status

I Agree to the Electronic Signature Terms

Patient / Responsible Party

Today's Date

Test File Upload

Reason for Visit

What are you seeking help with?

Is there a secondary problem area?

Does the Pain Radiate?

No Right Left Both

If so, Where to?

Does the Pain Radiate?

No Right Left Both

If so, Where to?

Prior Imaging

We want to maximize your time with Dr. Rupert. Exceptional, targeted care requires a real-time review of your diagnostic imaging. To ensure we can move forward with your treatment plan, your scans must be accessible before (best) or at the time of your visit; otherwise, we may need to reschedule your appointment.

Please provide any physical imaging discs immediately upon arrival so our team can instantly sync them to your digital chart.

Imaging Studies

Have you had Surgery or Injections for this?

Yes No

Please list

What have you been told the problem is? By whom?

What treatments or solutions have you been offered?

What do you think the problem is?

What is an acceptable outcome?

Are there any specific quesitons you would like Dr. R to address during your visit?

Cheif Complaint History

How long have you been seeking care?

Was there and inciting event?

(Approximately) When did the problem start?

How many providers or specialists have you worked with?

Pain Frequency and Severity

Most of the Time

Frequently

Intermittently

Have you gone to the ER for this?

No Yes

Number of Times

Over wwhat time frame?

List positions or physical activities that alleviate the symptoms?

List positions or physical activities that worsen or provoke the symptoms?

What word(s) describe the problem

Burning, Numbing, Tingling Deep, Dull, Aching Jolts/Stabbing Muscular Cramping

For JOINT pain - Do you have the following?

Swelling or Effusion / Fluid Decreased Range of Motion Abnormal Sounds / Grinding

For NERVE pain - Do you have the following?

Discoloration Regional Temperature Changes Nail or Hair Growth Changes

Have you tried the following?

NSAIDs or Tylenol > 3 weeks PT / Home Exercise > 6 weeks Activity Modification > 6 weeks

Demographics

Home Address

Photo ID / DL (Front)

Photo ID / DL (Back)

HIPAA Acknowledgment

First Name

Last Name

DOB

Phone

Demographics

Home Address

Photo ID / DL (Front)

Photo ID / DL (Back)

Do You Intend to Utilize Insurance Benefits

Yes No

Do You Have REGENEXX Coporate Benefits

Yes No

Primary Insurance Company

ID#

Group#

First Name on Card

Last Name on Card

Cardholder DOB

Insurance Card (Front)

Insurance Card (Back)