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Book Appointment (516) 579-4949

Address
3000 Hempstead Tpke #112,
Levittown, NY 11756 US

Phone
(516) 579-4949

Address
3000 Hempstead Tpke #112,
Levittown, NY 11756

Book Appointment (516) 579-4949

(516) 579-4949

Home
About Us
Contact Us
- Schedule an Appointment
Services
Patients
Blog

Home

New Patient Forms

New Patient Forms

Dr. Michael A. Bernstein

Chiropractor

3000 Hempstead Turnpike

Suite 112

Levittown, NY 11756

(516) 579-4949 Phone (516) 579-5078 Fax

www.spinefixer.com

Name*

Phone *

Cell Phone Carrier *

Email *

Your Primary Care Doctor

We Are Completely Committed To Improving Your Health Through Chiropractic Care

MICHAEL A BERNSTEIN, DC 3000 HEMPSTEAD TPKE., SUITE 112, LEVITTOWN, NY 11756 CHIROPRACTIC REGISTRATION AND HISTORY

PATIENT INFORMATION

Date *

Patient*

Address*

E-mail*

Sex

Male Female

Age

Birth Date

Status

Patient SS#

Occupation

Employer

Spouse's Name

Referred By

Primary Care Physician

INSURANCE

Who is responsible for this account?

Relationship to Patient

Birth Date

Insured' s SS#

Insurance Co.

Group#

Is Patient covered by additional insurance?

Yes No

Insurance Co.

Group/Policy#

ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependant) have insurance coverage with

and assign directly to Dr. Bernstein all insurance benefit if any, otherwise is payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

PHONE NUMBERS

Home

Work

Ext

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT

Name

Relationship

Home Phone

Work Phone

ACCIDENT INFORMATION

Date

Is condition due to accident?

Yes No

Type of accident:

To whom have you made a report of your accident?

Attorney Name (if applicable)

PATIENT CONDITION

Reason for visit

When did your symptoms appear?

Is this condition getting progressively worse?

Yes No Unknown

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)

Type of pain

Sharp Dull Throbbing Numbness Aching Cramps Shooting Burning Tingling Stiffness Swelling

How often do you rave this pain?

Is it constant or does it come and go?

Does it interfere with your Work, Sleep, Daily Routine, Recreating?

Activities/Movements that are painful to perform

Sitting Standing Walking Bending Lying Down

HEALTH HISTORY

What treatment have you already received for your condition? (Please circle all that apply)

Medical Surgery Physical Therapy Chiropractic None

Other

Name and address of other doctor(s) who have treated you for your condition

Have you ever received Chiropractic Care?

Yes No

If yes, when?

List Previous Surgeries you've has (with dates):

Family Health History:

Associated Health Problems of immediate relatives:

Deaths in immediate family (cause and age at death)

Place a check on the boxes to indicate if you have had any ol' the following:

AIDS/HIV Alcoholism Allergy Shots Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Bronchi1is Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Fractures Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia Herniated Disc Herpes High Blood Pres. High Cholesterol Kidney Disease Liver Disease Loss of Bowel / Bladder Function Measles Migraines Mononucleosis Multiple Sclerosis Mumps Osteoporosis Pacemaker Parkinson's Pinched Nerve Pneumonia Polio Prosthesis Psychiatric Care Rheumatoid Arth. Scarlet Fever Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Tumors/Growths Typhoid Fever Ulcers Venereal Disease Whooping Cough

Females

Breast Lump Full-Term Pregnancy Miscarriage Vaginal Infection

Males

Prostate Problem Erectile Dysfctn.

Are you pregnant?

Yes No

Due Date

EXERCISE LEVEL

None Moderate Daily Heavy

WORK ACTIVITY

Sitting Standing Light Labor Heavy Labor

SOCIAL HABITS

Smoking Alcohol Coffee/Caffeine High Stress Level

MEDICATIONS/DOSAGES

ALLERGIES

VITAMINS/HERBAL/MINERALS

PATIENT CONSENT

FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

___________________________________ hereby states that by signing this consent, I acknowledge and agree as follows:

Insert your answer here for the blank space above

1. The office of Michael A. Bernstein, DC, PC (hereafter known as The Practice) Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information ("PHI") necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the privacy notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.

2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in

accordance with applicable law.

3. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) a postcard mailed to me at the address provided by me; b) telephoning my home and leaving a message on my answering machine or with the individual answering the phone; and c) ,using email and/or text messages at the email address/phone number provided by me.

4. The Practice may use and,/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations.

5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.

6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at anytime for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this Consent.

7. I understand that if I revoke this Consent at any time, the Practice has the right to refuse to treat me.

8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice will not treat me.

Custom Field

I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand. .

Informed Consent To Chiropractic Adjustments And Care

I have an opportunity to discuss with the doctor of chiropractic named below and/ or with other office or clinic personnel, the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.