Medical In-Take And History Form

    Personal Information








    Your Gender







    Person Responsible For Payment

    If other than you









    Insurance Information







    Medical History



    Past Medical History - Please check all that apply

    Medications

    Social History - Please check all that apply

    Cigarette Smoker

    Sexual Activity - Optional

    If sexually active

    Drug Use

    Alcohol Use

    Pharmacy Information



    Signature

    I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION TO MY PRIMARY CARE OR REFERRING PHYSICIAN, TO CONSULTANTS IF NEEDED AND AS NECESSARY TO PROCESS INSURANCE CLAIMS, INSURANCE APPLICATIONS, AND PRESCRIPTIONS. I ALSO AUTHORIZE PAYMENTS OF MEDICAL BENEFITS TO PALMS ACUPUNCTURE AND WELLNESS.

    PAYMENT IS REQUIRED FOR ALL SERVICES AT THE TIME THEY ARE RENDERED. I HAVE HAD A CHANCE TO READ OVER THE FINANCIAL RESPONSIBILITY FORM.

    Signature of patient or responsible party

    If you are the responsible party signing for the patient please indicate your relationship to the patient

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