Previous Patient – Dr. Brian Cox

Name *

First

Last

Birth Date *//

Email *

Phone

Address *

City *

State *

Zip Code *

Do you have a primary doctor? *

Yes
No

Do you have health insurance? *

Yes
No

Who is your primary doctor? *

Who is your health insurance provider? *

Insurance subscriber's name *

Insurance subscriber's birth date *

Suffix *

ID number *

Please upload images of the FRONT AND BACK of your insurance card if you can

Since Last Visit

Last in Office On *//

Best estimation if you aren't positive

Last in Office for *

Any NEW injuries since last visit? *

What and where is the Injury? *

When was the Injury? *//

Any NEW surgeries since last visit? *

What and where was the surgery? *

When was the suregery? *//

Any NEW tests since last visit? *

What tests were done? *

When where these tests done? *//

Estimate if you are not sure

If you have a copy of the results upload them here

About Your Problem

Where is your current MAIN problem? *

Side of problem *

What are your symptoms there? (all that apply) *

What OTHER symptoms do you have there? *

Rate symptoms from 0-10 *

What % of the day are symptoms? *

When did this current flare up start? *//

Estimate if need

How did this flare up begin? *

What OTHER way did this flare up begin *

What is this problem MOST limiting you from doing normally? *

What OTHER thing is the limiting you from doing normally? *

Authorization and Release

I authorize my insurance benefits to be paid to Brian Cox PT & Chiro (if applicable).

I consent to the release of my diagnostic reports to Brian Cox PT & Chiro.

I will pay for all fees not covered by my insurance.

I agree to email correspondence with Brian Cox PT & Chiro.

I had opportunity to review the notice of privacy practices listed below this form.

I confirm that the information above is accurate and complete.

Confirmation and Signature

The "E-signature" below stands in place of a physical legal signature confirming that I agree to the terms listed under Authorization and Release.

Check here if signing for your child

I authorize Brian Cox PT & Chiro for treatment of my child

Name of Child *

E-Signature *

First and Last Legal Name

E-Signature of Parent/Guardian *

First and Last Legal Name

Date *//

Date of E-Signature

Date *//

Date of E-Signature

PREVIOUS PATIENTS

PREVIOUS PATIENTS

Since Last Visit

About Your Problem

Authorization and Release

Confirmation and Signature

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