New Patient Information

Male Female

No known allergies to report

All of the time    
When active   
Climbing stairs   
Being active   
Occasionally    Comes and goes    Frequently     Constantly   
Self care   
Daily routine   
Activity moderation   
Over-the-counter medication   
Prescription medicine   

Health Insurance
Auto Insurance
Self Pay

Denies any use of medications or supplements

Denies past surgeries and/ or hospitalizations

No Yes
No Yes
No Yes
No Yes
No Yes
Low Moderate High
Single    Partnered    Engage     Married    Divorced     Widowed    Other
Alone Roommate Family

Condition No Current In the Past Year Diagnosed and Additional Information

Mental Illness
Memory Loss
Substance Abuse
Behavioral Change

Environmental Allergies
Runny Nose
Watery Eyes
Food Intolerance

Suspicious Moles
Nail Changes
Hair Changes

I understand and agree that if I have health and/or accident insurance policies, that these policies are an arrangement between my insurance company and myself. Any amount paid to this office will be credited to my account upon my receipt. I understand that my insurance policies may cover part, or none of the services rendered. I clearly understand and agree that all services rendered to me are my personal responsibility.

Late cancellations of less than 2 hours, and patients who do not show for a scheduled appointment will be charged $25.00. We do not accept walk-in appointments.

I would like to be reminded the day before my appointments via text message
I would like to be reminded the day before my appointments via email
I do not need to be reminded of my appointment

I authorize the direct payment to my doctor from my insurance company that is contractually obligated to pay my doctor directly out of any proceeds of any settlement I may receive. A photocopy of this form is acceptable for this authorization.

I authorize this office to release any information requested by a third party that presents a signed release bearing my signature.

I acknowledge that Physical Healthcare of Jacksonville provides the opportunity to review the Notice of Privacy Practices. The Notice of Privacy Practices describes the type of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operation at Physical Healthcare of Jacksonville. The Notice of Privacy Practices for Physical Healthcare of Jacksonville is also provided on request at the main administration desk. The Notice of Privacy Practices also describes my rights and Physical Healthcare of Jacksonville’s duties with respect to my protected health information. Physical Healthcare of Jacksonville reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a copy or by asking for one at the time of my next appointment.

I have read, fully understand and agree to abide by the above policies

A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare case, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. This office does not perform breast, pelvic, prostate, rectal, or full skin evaluations. These examinations should be performed by your family physician, GYN, and dermatologist to exclude cancers, abnormal skin lesions that should undergo biopsy/removal or other treatments. This clinic does not provide care for any condition (such as high blood pressure, diabetes, high cholesterol) other than those addressed in your physical medicine care plan. We also do not prescribe or refill ANY controlled substances. All prescriptions should be refilled by your original prescriber and any new prescriptions should be issued by your primary care provider.

The patient assumes all responsibility/liability if the patient does not report on health forms any past medical history, illnesses, medicines, or allergies.

I agree to settle any claim or dispute I may against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.

I have read and understand the above consent form.

I acknowledge that I have reviewed the Notice of Privacy Practices of
(Please initial one of the following options and sign below.)

I wish to receive a paper copy of Privacy Notice.

I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office. If I should have a problem or question in regard to my rights, I may speak with the Privacy Officer about my concerns.

This serves a notice that as part of our efforts to deliver the most consistent healthcare we can to every patient, we use an electronic healthcare system that enables us to retrieve up to 13 months of prescription history through your insurance carrier.

I acknowledge that it is the policy of this office to leave reminder messages on my answering machine or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing.

Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your condition. Should x-rays be necessary we would like to confirm that you are not pregnant or aware of any other conditions at this time which would conflict with taking x-rays. By signing, you understand that there are risks associated with x-rays and that you give consent to receive x-rays if the Physician deems them necessary.

Yes No
Yes No

As healthcare providers we are concerned about your overall wellness. On future visits we will discuss issues wit you that may impact your overall health.

All of the answers I have given are correct to the best of my knowledge, and I agree to have an examination performed at Physical Healthcare of Jacksonville at this time.