Page | 1 UPLAND ACUPUNCTURE & WELLNESS PATIENT INFORMATION FORM (Please Print) Best method to send appointment reminders: □ Phone □ Text □ Email Are you a vegan or vegetarian? □ Yes □ No Today’s Date: MM / DD / YYYY PATIENT INFORMATION Last name: First: Middle: Is this your legal name? □ Yes □ No Sex: □ M □ F □ Other Prefer to be called by: Driver License# & Issued State: Legal Guardian (if under 18): Birth Date: MM / DD / YYYY Age: Home Address: City State Zip Best Contact#: □ Cell □ Home □ Work __________-__________-______________ May we leave appointment info in message? □ Yes □ No Social Security# __________-________-____________ Marital Status: □ Single □ Married □ Separated/Other E-mail Address: ___________________________________ How did you hear about us? □ Insurance □ Yelp/Google □ Close to Work □ Friend/Family (name)___________________________ □ Other _____________________ □ Professional Referral (name)___________________________________________________ EMPLOYMENT INFORMATION □ Employed □ Student □ Retired □ Other:______________________ Employer: ____________________________________ Occupation: _________________________________________________ Work Phone#: ________-________-____________ ACCIDENT/INJURY INFORMATION □ Auto Accident □ Work Injury □ Sport / Hobby Injury □ Personal Injury Is the condition due to an accident? □ Yes □ No Have you report the injury? □ No □ Yes. To whom did you report the accident to? ___________________________________________ HEALTH INSURANCE INFORMATION Insurance Company Name: Group #: ID / Claim #: IN CASE OF EMERGENCY Contact Name (not living at same address): Relationship to Patient: Contact #: ________-________-____________ Work #: ________-________-____________ I certify that if I, and/or my dependent(s), have insurance coverage, I shall assign to Upland Acupuncture & Wellness and/or its affiliates all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature or all insurance submissions. I also understand that sending in my insurance claim is a courtesy and not a requirement. Upland Acupuncture & Wellness and its affiliates/agents may use my health care information and may disclose such information to the health care insurance companies and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I have read the privacy practices of this practice. I intend this consent to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due. X Patient/Guardian Signature Date
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UPLAND ACUPUNCTURE & WELLNESS PATIENT …...Men Only ☐ None / Doesn’t ... • Herbal/Nutritional supplements: The herbs and nutritional supplements (which are from plants, animal
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UPLAND ACUPUNCTURE & WELLNESS PATIENT INFORMATION FORM
(Please Print)
Best method to send appointment reminders: □ Phone □ Text □ Email
Are you a vegan or vegetarian? □ Yes □ No Today’s Date: M M / D D / Y Y Y Y
PATIENT INFORMATION
Last name: First: Middle:
Is this your legal name? □ Yes □ No
Sex:
□ M □ F
□ Other
Prefer to be called by: Driver License# & Issued State: Legal Guardian (if under 18): Birth Date: M M / D D / Y Y Y Y
Occupation: _________________________________________________ Work Phone#: ________-________-____________
ACCIDENT/INJURY INFORMATION
□ Auto Accident □ Work Injury □ Sport / Hobby Injury □ Personal Injury Is the condition due to an accident? □ Yes □ No
Have you report the injury? □ No □ Yes. To whom did you report the accident to? ___________________________________________
HEALTH INSURANCE INFORMATION
Insurance Company Name:
Group #:
ID / Claim #:
IN CASE OF EMERGENCY
Contact Name (not living at same address): Relationship to Patient:
Contact #: ________-________-____________ Work #: ________-________-____________
I certify that if I, and/or my dependent(s), have insurance coverage, I shall assign to Upland Acupuncture & Wellness and/or its affiliates all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature or all insurance submissions. I also understand that sending in my insurance claim is a courtesy and not a requirement. Upland Acupuncture & Wellness and its affiliates/agents may use my health care information and may disclose such information to the health care insurance companies and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I have read the privacy practices of this practice. I intend this consent to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due.
X Patient/Guardian Signature Date
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UPLAND ACUPUNCTURE & WELLNESS PERSONAL HEALTH HISTORY QUESTIONNAIRE