Patient Registration
Details below need to be updated yearly.
Update any information that has changed.
Name
*
Email
*
Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
2nd Phone
Please enter a valid phone number.
Format: 0000000000.
Date of Birth Existing PT.
Date of Birth
*
/
Month
/
Day
Year
Social Security Number
Last four digits is acceptable.
Preferred State For Treatment
*
Please Select
Maryland
Pennsylvania
Florida
Virginia
Ohio
We have office in Maryland, Pennsylvania, Virginia, Florida, and Ohio
Contact Preference
*
Please Select
TEXT FORM
EMAIL FORM
Would you prefer that we text or email you forms?
Your Home Address
*
Street
Street Address Line 2
City
STATE ABBREVIATION ONLY. PLEASE CHECK SPELLING
Postal
Athena ID
*
How did they hear value
Referral Text Value
How did you hear about us:
*
Insurance
Internet
Friend
Attorney
Social Media
Drive-by
Healthcare Provider
Billboard
Walk-In
Family
Your Website
Self-Referral
Other
None of the Above
Name of Friend
Leave blank if you do not want to say
Enter Details Here
Write "Unknown" if unsure
Full Name of Attorney
Leave blank if you do not want to say
Name of Insurance
Leave blank if you do not want to say
What Social Media Platform
Type Unknown if Unsure
Referrer Value First
Referrer Value Last
Grouping
Referring Provider (First Name)
Referring Provider (Last Name)
Referring Provider Name
*
Name of Referrer Facility
*
Referrer City and State
*
Referrer Specialty
*
Enter NA is unkown
Referrer Fax
Referrer Phone Number
Have you had previous pain management in the past five years?
*
Yes
No
Name of Your Provider
*
Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Pain Concern:
*
Current Pain Medications:
*
Pain Management Result
Are You On Blood Thinners?
*
Yes
No
BLOOD
List Your Blood Thinner Medication:
*
Primary Care Provider Name
*
Primary Care Provider Phone Number
Enter unknown if unsure
Primary Care Provider Fax
*
Enter unknown if unsure.
Primary Care Provider Location
*
Enter General Area (City) or Enter Unknown
Have you previously been treated by a pain management provider?
*
Yes
No
Prior Pain Physician Information
*
Last Time Seen
*
Physical/chiropractic therapy:
*
Yes
No
physical / chiro result
Physical Therapy Location
*
Physical Therapy Phone Number
Please enter a valid phone number.
Format: 0000000000.
Radiology in past year?
*
Yes
No
radiology result
Radiology Location
*
Radiology Phone Number
Please enter a valid phone number.
Format: 0000000000.
Females: Are you pregnant or breast feeding?
*
Yes
No
female result
OBGYN Provider
*
OBGYN Provider Phone Number
Please enter a valid phone number.
Format: 0000000000.
Is this related to W/C or an auto accident?
*
Yes
No
WC result
W/C Insurance
*
Claim #
*
DOI
*
Adjuster Name
*
Adjuster Phone #
Adjust Fax
Attorney Name
Attorney Phone
Claims Mailing Address
Street Address Line 2
Has Your Insurance Information Changed?
*
YES
NO
Please double check your insurance information:
Primary Insurance:
*
Letters Only - Parentheses and Dashes not allowed
Insurance ID:
*
Primary Policy Holder Name
*
Relation
*
Primary Holder: Date of birth
/
Month
/
Day
Year
Primary Sequence
Insurance One DOB
Secondary Insurance:
Letters Only - Parentheses and Dashes not allowed
Secondary ID #:
2nd Policy Holder Name
2nd Insurance Relation to patient
2nd Holder Date of Birth
/
Month
/
Day
Year
Secondary Sequence
Insurance TWO DOB
Patient Signature
24 hour notice must be given if cancelling or rescheduling
If not there will be a $75 fee.
Appointment Date
/
Month
/
Day
Year
Date
Appointment Time
Hour Minutes
AM
PM
AM/PM Option
Appointment Date
Appointment Time
Appointment Provider
Appointment Location
Appointment Address
Pre-Appointment Checklist:
Arrive 30 minutes prior to appointment to complete Health Note
List of current medications
Any radiology reports / medical records
Health Note sent / Emailed
Bring photo ID & insurance cards
Informed referral needed from PCP (Wellpoint, Johns Hopkins/Priority Partners, United Healthcare "on portal", Jai Medical, Tricare, HMO Plan)
SUBMIT AND CONTINUE
HEALTH NOTE TRIGGER
Send
Not Sent
Status
Sent Date
-
Month
-
Day
Year
Date
STATE
Treatment Location
Form Send Selection
Contact Type
How they heard about us
space
Patient Type
Full Name
Address Full
New or Existing
Appointment Type
Admin Email
CHATBOX STATUS
Questionnaire Send Type
NEW PATIENT
EXISTING PATIENT
CHOOSE
NEW FILL
EXISTING FILL
Patient Type Calculated
masterid
dob (text)
SENDER NAME
1. Relation To Patient
Please Select
Self
Spouse
Child
Child (Mother's Insurance)
Child (Father's Insurance)
Other
Grandparent
Grandchild
Aunt or Uncle
Nephew or Niece
Foster Child
Ward
Charge of a Caretaker
Stepson or Stepdaughter
Stepson or Stepdaughter (Stepmother's Insurance)
Stepson or Stepdaughter (Stepfather's Insurance)
Sibling
Employee
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent of a Minor Dependent
Significant Other
Mother
Father
Parent
Stepparent
Emancipated Minor
Organ Donor
Cadaver Donor
Injured Plaintiff
Child (Ins. not Financially Respons.)
Child (Mother's Ins., Ins. not Financially Respons.)
Child (Father's Ins., Ins. not Financially Respons.)
Life Partner
Questionnaire Type
Send Questionnaire ID
Previous Questionnaire ID
INTAKE Re-Filled
title
Check-in Submission ID
Check-In (formstosend)
Primary Insur Relation ID
Sequence Number Primary Insurance
Please Select
1
2
2. Relation To Patient
Please Select
Self
Spouse
Child
Child (Mother's Insurance)
Child (Father's Insurance)
Other
Grandparent
Grandchild
Aunt or Uncle
Nephew or Niece
Foster Child
Ward
Charge of a Caretaker
Stepson or Stepdaughter
Stepson or Stepdaughter (Stepmother's Insurance)
Stepson or Stepdaughter (Stepfather's Insurance)
Sibling
Employee
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent of a Minor Dependent
Significant Other
Mother
Father
Parent
Stepparent
Emancipated Minor
Organ Donor
Cadaver Donor
Injured Plaintiff
Child (Ins. not Financially Respons.)
Child (Mother's Ins., Ins. not Financially Respons.)
Child (Father's Ins., Ins. not Financially Respons.)
Life Partner
2nd Insurance Relation ID
Sequence Number 2nd Insurance
Please Select
1
2
department
Current Date for Consent (formatted)
Consent Last Sent Date
SEND CONSENT?
Consent Last Sent Value
CURRENT Date for Consent
/
Month
/
Day
Year
Date
Form Referrer
Appointment ID
Send Consent (check-in form)
Form 1
Form 2
Form 3
Form 4
Form 5
Form 6
Form 7
Form 8
Form 9
Should be Empty: