Patient Information Form - Meridian Acupuncture & Wellness

We are currently working on updates to our online form. In the mean time, please use the printable PDF form: click here.

PATIENT INFORMATION

First Name:

Middle Inital:

Last Name:

Age:

Gender:

Date of Birth:

Home Address (street, city, state, zip):

Phone 1:

Type:

Phone 2:

Type:

Phone 3:

Type:

Phone number where we can leave you a message:

What is your preference for automated appointment reminders? Email Text No reminder

Email:

Employer:

Work Address (street, city, state, zip):

Weight:

Height:

Name you go by:

Emergency Contact:

Relationship:

Emergency Contact Phone:

Who referred you / how did you hear about MA&W?

INSURANCE INFORMATION

The insurance/billing information questions are necessary. Please provide your insurance ID card for photocopying.

Insurance Company:

Phone:

Insured's ID #:

Group #:

Birth Date:

As a service to our patients, Meridian Acupuncture & Wellness will submit the charges for medical treatment to the patient's insurance company. However, the patient is primarily responsible for paying any and all medical expenses incurred at this office. We may attempt to verify, in advance, that the patient's insurance company will pay for specific medical procedures. Occasionally, even though coverage was verified before the medical services were provided, the insurance company denies the claim. If the insurance company denies payment or will not pay a portion of the medical bill, the patient is responsible for payment of account balance. Likewise, if the patient has not met his/her deductible under a given insurance plan, the patient will be responsible for the amount of the deductible, in addition to whatever the insurance does not pay. For your convenience copays, coinsurance and deductibles are collected at the time of service.

Although we will verify insurance coverage for our records, we strongly encourage our patients to call their insurance company to verify their coverage prior to their first appointment.

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Meridian Acupuncture & Wellness. I also authorize my insurance company to release any information required to process claims. I agree to be responsible for payment of service in the event my insurance company does not agree to pay for these services. (Not signing this document does not release you from responsibility of payment.)

Patient’s or Authorized Person’s Signature:

Date:

From whom are you currently receiving health care?

What, if any, contagious disease do you have at this time?

What childhood illnesses have you had?

What allergies to drugs or food do you have?

What current medications do you take and for what?

List vitamins/supplements you are currently taking.

YOUR MEDICAL HISTORY:

Chronic or continuing illnesses:

Surgeries, major illnesses, hospitalizations, and major accidents (include year):

History of Childhood Trauma? Yes No

Are you a former smoker? Yes No

How many packs per day?

Are you a current smoker? Yes No

How many packs per day?

What was your last blood pressure reading?

What is your normal body temperature reading?

FAMILY HISTORY:

Age (if living)

Father: Mother: Brother(s): Sister(s): Child(ren):

Health (G=good P=poor)

Father: Mother: Brother(s): Sister(s): Child(ren):

WHAT BRINGS YOU HERE TODAY?

What is the reason for your visit today?

How, when, and where did this condition begin?

What types of treatments have you tried, if any?

How does this condition impair your daily activities?

SYSTEMS REVIEW (Please select all that apply)

GROUP 1

GROUP 2

GROUP 3

GROUP 4

GROUP 5

GROUP 6

GROUP 7A

GROUP 7B

GROUP7C

GROUP7D

GROUP 7E

GROUP 7F

GROUP 8

Thank you for taking the time to fill out this form as completely as possible. Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient’s physical, mental and emotional state.

Patient's Name:

Date: