Schedule Appointment Home » Schedule Appointment Contact Us Request an Appointment New Patient, Returning Patient, and Active Patient intake with conditional service-line trigger blocks. Who Are You?I am a...(Required) New Patient - never been seen here Returning Patient - established but have not been seen in 6+ months Active Patient - currently in care / seen within the last 6 months Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Legal Sex(Required) Female Male Intersex Prefer not to say Preferred NamePronounsMobile Phone(Required)Email(Required) Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Language(Required)EnglishSpanishOtherNoneInterpreter needed?(Required) Yes No How did you hear about us?(Required)FriendDoctorGoogleReviewsSocialWalk-InEventEmployerInsuranceReturningOtherFriend name(Required)Social platform(Required)Referring provider name(Required)What Brings You In?Primary Reasons(Required) Pain Management (PRP, joint, epidural injections) Sports Medicine Sports Chiropractic Physical Therapy Acupuncture Foot & Ankle / Podiatry Spine & Orthopedic Care Hand Surgery Athletic Recovery / Injury Prevention Regenerative Medicine (Stem Cell, BMAC, Shockwave/EPAT, Peptides, NAD+) Pre-Op / Post-Op Care Coordination Occupational Therapy Neurology / Nerve Testing (EMG) Rheumatology / Autoimmune Care Hormone Replacement Therapy (HRT) - Testosterone, Menopause, Peptides Medical Weight Loss (GLP-1, Semaglutide, Tirzepatide) IV Vitamin Therapy Wellness / Lean Muscle Gain Allergy & Immunology (environmental, food testing, SLIT) Primary Care - new PCP / sick visit / chronic management Annual Adult Physical VIP Physical / Athlete Readiness Exam Cardiopulmonary / Captain Buscio Physical Sleep Study / Sleep Health Pulmonary / PFT (Breathing & Lung Function) Imaging (X-ray, Diagnostic Ultrasound) Laboratory / Blood Work (Preventive, Hormone, Autoimmune panels) MRI Review Vein / Vascular Care Flu Shot / Immunization Workers' Compensation Injury Personal Injury / Motor Vehicle Accident Slip and Fall Select all primary reasons for this appointment.Secondary reasons Pain Management (PRP, joint, epidural injections) Sports Medicine Sports Chiropractic Physical Therapy Acupuncture Foot & Ankle / Podiatry Spine & Orthopedic Care Hand Surgery Athletic Recovery / Injury Prevention Regenerative Medicine (Stem Cell, BMAC, Shockwave/EPAT, Peptides, NAD+) Pre-Op / Post-Op Care Coordination Occupational Therapy Neurology / Nerve Testing (EMG) Rheumatology / Autoimmune Care Hormone Replacement Therapy (HRT) - Testosterone, Menopause, Peptides Medical Weight Loss (GLP-1, Semaglutide, Tirzepatide) IV Vitamin Therapy Wellness / Lean Muscle Gain Allergy & Immunology (environmental, food testing, SLIT) Primary Care - new PCP / sick visit / chronic management Annual Adult Physical VIP Physical / Athlete Readiness Exam Cardiopulmonary / Captain Buscio Physical Sleep Study / Sleep Health Pulmonary / PFT (Breathing & Lung Function) Imaging (X-ray, Diagnostic Ultrasound) Laboratory / Blood Work (Preventive, Hormone, Autoimmune panels) MRI Review Vein / Vascular Care Flu Shot / Immunization Workers' Compensation Injury Personal Injury / Motor Vehicle Accident Slip and Fall None Select any additional concerns, or choose None.Pain / Musculoskeletal / Recovery DetailsPrimary area of pain(Required)NeckMid BackLow BackHipKneeShoulderElbowWrist/HandFoot/AnkleHeadPelvic/SIMultipleNoneWhen did it start?(Required)What makes it better?(Required)What makes it worse?(Required)Pain level today(Required)012345678910Numbness, tingling, weakness, instability?(Required) Yes No Describe numbness, tingling, weakness, or instability(Required)Have you tried treatment already?(Required) PT Injections Surgery Meds Chiro Acupuncture None Treatment details and dates(Required)Any imaging done?(Required) X-ray MRI Ultrasound None Imaging facility name(Required)Upload imaging report(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Prior epidurals, joint injections, PRP, or surgeries on this area?(Required) Yes No Prior procedure type/date(Required)Primary Care / Sick Visit DetailsDo you currently have a PCP?(Required) Yes No If yes, are you looking to switch or seeking a second opinion? Why?(Required)When was your last physical?(Required)When was your last full bloodwork?(Required)Top 3 concerns you want addressed(Required)Chronic conditions you are managing(Required) High blood pressure Diabetes Thyroid Cholesterol Other None Sick visit symptoms(Required) Cough Sore throat Fever Body aches GI Sinus Ear UTI symptoms Rash Other None How many days have you had symptoms?(Required)Highest temperature recorded(Required)Known exposure(Required) Flu COVID Strep None Have you taken anything for it already?(Required)Chronic conditions that make this worse(Required) Asthma COPD Immunocompromised None HRT / Hormone DetailsSymptoms you are experiencing(Required) Low energy Low libido Brain fog Weight gain Mood Sleep Hot flashes ED Irregular cycle Menopausal symptoms None Currently on HRT, testosterone, or peptides?(Required) Yes No If yes, what specifically, dose, prescriber, how long, last labs?(Required)Hormone bloodwork in the last 12 months?(Required) Yes No Upload hormone bloodwork if available(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Trying to conceive?(Required) Yes No History of contraindications(Required) Blood clots Prostate issues Breast cancer Liver disease None Medical Weight Loss DetailsCurrent height(Required)Current weight(Required)Target weight(Required)Currently on a GLP-1?(Required) Yes No Current GLP-1 details(Required)Past GLP-1 use?(Required) Yes No Past GLP-1 details(Required)Relevant history(Required) Pancreatitis Gallbladder disease Thyroid C-cell tumor MEN2 Eating disorder None What have you tried before?(Required) Diet programs Surgery Meds None IV Therapy DetailsGoal of this IV(Required)Hydration after illnessHangover/recoveryEnergy/vitamin boostImmune supportAthletic recoveryMigraineNAD+OtherHad an IV here or elsewhere before?(Required) Yes No History requiring nurse review(Required) Kidney disease Heart failure G6PD deficiency None STEP 3 - Allergy / SLIT DetailsSymptoms(Required) Sneezing Congestion Itchy eyes Hives GI Asthma Anaphylaxis history None Are symptoms seasonal, year-round, or food-related?(Required) Seasonal Year-round Food-related Tested before?(Required) Skin prick Blood Neither Upload prior allergy results if available(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Currently on antihistamines, steroids, or biologics?(Required)History of anaphylaxis or epinephrine use?(Required) Yes No Sleep Study DetailsKeep existing Epworth-style screener questions here after import.Sleep health screener(Required)Has a partner observed you stop breathing? Yes No Prior sleep study details(Required)Currently using CPAP / BiPAP / oral appliance?(Required)Vein Care DetailsKeep existing leg-symptom screener questions here after import.Vein health screener(Required)Prior vein procedure(Required) Sclerotherapy Ablation Vein stripping None DVT or PE history(Required)Currently on blood thinners?(Required) Eliquis Xarelto Coumadin Aspirin Other None Annual / VIP Physical DetailsReason for the physical(Required)RoutineEmployer requiredAthletic clearanceLife insuranceSurgery clearanceOtherLast physical date and provider(Required)Specific concerns for this physical(Required)VIP add-ons interested in(Required) Body composition (SECA) Micronutrient panel Hormone panel None MRI Review DetailsBody part imaged(Required)Date of MRI(Required) MM slash DD slash YYYY MRI facility(Required)Upload MRI report(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Upload images / disc info if available(Required)Has another provider reviewed it? Who?(Required)Questions you want answered(Required)Pre-Op / Post-Op DetailsWhat surgery?(Required)Surgeon(Required)Surgery date(Required) MM slash DD slash YYYY Pre-op clearance or post-op follow-up?(Required) Pre-op clearance Post-op follow-up If post-op, what week post-op are you?(Required)Upload op report or surgeon notes if available(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Workers Comp / PI / MVA DetailsMandatory claim details. Do not book without required claim/adjuster details.Date of injury(Required) MM slash DD slash YYYY Type(Required) MVA Slip and fall Workplace Other Claim #(Required)Adjuster nameAdjuster phoneBody parts injured(Required) Neck Back Shoulder Knee Foot/Ankle Head Multiple Other None Seen elsewhere for this injury? Facility + provider(Required)Upload police report, accident report, MRI, or prior records(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Medical History - New PatientsDrug allergies and reactions(Required)Any reaction to anesthesia or contrast dye?(Required) Yes No Describe anesthesia or contrast reaction(Required)Current Rx, OTC, supplements, vitamins, peptides, HRT, GLP-1s(Required)Past medications / therapies stopped in last 5 years and why(Required)Past surgeries and hospitalizations(Required)Past / current conditions(Required) Anxiety Depression Asthma / COPD Sleep Apnea Diabetes Type 1 Diabetes Type 2 Prediabetes Thyroid Condition High Blood Pressure High Cholesterol Heart Disease / Heart Attack Stroke / TIA Cancer Autoimmune Arthritis / Osteoarthritis Osteopenia / Osteoporosis GERD / Reflux IBS / IBD / Crohn's Kidney Disease Liver Disease Anemia Bleeding/Clotting Disorder Migraine Seizure Disorder Erectile Dysfunction Low Testosterone Insomnia / Chronic Fatigue Eating Disorder History Recurrent Sprains / Joint Instability Concussion / TBI History None Family history(Required)Social history(Required)Female patients only - pregnancy, nursing, LMP, menopause, birth control(Required)Returning Patient UpdatesShortened update block for returning patients.New diagnoses, surgeries, hospitalizations, ER visits, or specialists seen?(Required)New medications started or stopped?(Required)New allergies?(Required)New insurance, employer, pharmacy, or address?Upload new driver's license or insurance cardAccepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Emergency Contact + ConsentEmergency Contact Name(Required) First Last Emergency Contact Relationship(Required)Emergency Contact Mobile Phone(Required)Emergency Contact Home Phone(Required)Emergency Contact Email(Required) HIPAA Notice of Privacy Practices(Required) I have read and acknowledge the HIPAA Notice of Privacy Practices.Consent to Treat / Financial Responsibility(Required) I understand and agree to consent to treat and financial responsibility.Communication preferences(Required) OK to text OK to email OK to leave voicemail None Photo / Video Consent(Required) I consent to photo/video use where applicable.Scheduling PreferencesScheduling preferences and telehealth eligibility.Preferred day(s)(Required) Mon Tue Wed Thu Fri Sat None Preferred time of day(Required) Morning Mid-day Afternoon Evening None In-person or telehealth eligible?(Required) In-person Telehealth Only visible for approved telehealth-capable visit types.How quickly do you need to be seen?(Required) Same day This week Next 2 weeks Flexible Insurance + PharmacyPrimary Insurance - Holder NameRelationship to holder Self Spouse Parent Insurance Company(Required)Member ID(Required)Group #Insurance PhoneUpload Insurance Card FRONT(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Upload Insurance Card BACK(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Upload Driver's License(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Upload Rx Card if separateAccepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Do you or your spouse have a secondary insurance that may cover copays, coinsurance, or deductibles? Yes No I'm not sure Secondary Insurance - Holder NameSecondary Insurance CompanySecondary Member IDSecondary Group #Upload Secondary Insurance CardAccepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Does your spouse or partner have a different insurance plan than yours? Yes No N/A Would you like to add it as your secondary? Yes No Do you have an HSA or FSA card? Yes No I'm not sure HSA / FSA Card Type Standalone debit card Linked to my primary plan I'm not sure HSA / FSA Card IssuerHSA / FSA Card Holder NameUpload HSA / FSA CardAccepted file types: pdf, jpg, jpeg, png, Max. file size: 220 MB. Preferred Pharmacy NamePharmacy PhonePharmacy Full Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specialty pharmacy? Yes No Different specialty pharmacy for specific meds?Mail-order pharmacy?Workers Comp / PI / MVAW/C or Auto CarrierAdjuster NameClaim # - billingAdjuster PhoneDate of injury - billing(Required) MM slash DD slash YYYY Attorney info if applicable Consent form. View consent form × I have viewed and agree to the consent form above(Required) Yes Signature(Required)
