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Convenient Downtown NYC Location
Home > New Patient Center > New Patient Health History Online Form
We need to know your condition and what discomforts you are experiencing so that we may treat you with the proper therapies.
The new patient evaluation starts with filling out a form, and then a meeting with the doctor. The doctor will conduct various tests to ascertain soreness, sensitivity, and range of motion.
The doctor will also discuss some of your responses on this form.
All new patients are required to fill out this form prior to examination. Online completion of the form will eliminate the need to do so in our waiting room on your first visit.
The doctor will review your information during your initial visit and discuss your responses.
This form is required and will help ensure that none of your symptoms are overlooked.
Your responses on this online form are encrypted, and safe from view by anyone but the doctor.
Nature of Injury
*If an auto accident, please provide:
Name of the Insured _____________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Patient's signature _______________________________________________
Spouse's or guardian's signature __________________________________