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This field is for validation purposes and should be left unchanged.

Patient Type

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

About You

Patient Name(Required)

First Last

Date of Birth(Required)

Legal Sex(Required)

Female

Male

Intersex

Prefer not to say

Preferred Name

Pronouns

Mobile Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Language(Required)

Interpreter needed?(Required)

Yes

How did you hear about us?(Required)

Friend name(Required)

What Brings You In?

Reasons for this visit(Required)

Other reason for visit(Required)

Do any of these apply to you?(Required)

Pain, Musculoskeletal, and Recovery

Are you currently experiencing any of the following?(Required)

Primary area of pain(Required)

How severe is your pain today?

0 = none, 10 = worst

Tell us more about your pain or symptoms

Onset, better/worse, prior treatment, numbness/tingling/instability

Any imaging done?(Required)

X-ray

MRI

Ultrasound

None

Upload imaging report

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Prior epidurals, injections, or surgeries?(Required)

Yes

Primary Care / Sick Visit

Do you currently have a PCP?(Required)

Yes

If yes - switching or seeking a second opinion? Why?

When was your last physical?

When was your last full bloodwork?

Top 3 concerns you want addressed

Sick visit symptoms(Required)

Chronic conditions you are managing(Required)

High blood pressure

Diabetes

Thyroid

Cholesterol

Other

None

Sick visit details

Days of symptoms, highest temperature, known exposure, what you have taken, and any chronic conditions that may worsen symptoms

Hormone / HRT

Symptoms you are experiencing(Required)

Currently on HRT, testosterone, or peptides?(Required)

Yes

Hormone bloodwork in the last 12 months?(Required)

Yes

Upload hormone bloodwork if available

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Trying to conceive?(Required)

Yes

Not applicable

History of contraindications(Required)

Blood clots

Prostate issues

Breast cancer

Liver disease

None

Medical Weight Loss

Current height / weight / target weight

Currently on a GLP-1?(Required)

Yes

Past GLP-1 use?(Required)

Yes

What have you tried before?(Required)

Diet programs

Surgery

Meds

None

Relevant history(Required)

Pancreatitis

Gallbladder disease

Thyroid C-cell tumor

MEN2

Eating disorder

None

IV Therapy

Goal of this IV(Required)

Had an IV here or elsewhere before?(Required)

Yes

History requiring nurse review(Required)

Kidney disease

Heart failure

G6PD deficiency

None

Allergy / SLIT

Even if allergy care was not your main reason - do any of these apply?(Required)

Sneezing

Congestion

Itchy eyes

Hives

Asthma

Anaphylaxis history

None

Seasonal, year-round, or food-related?(Required)

Seasonal

Year-round

Food-related

Not applicable

Tested before?(Required)

Skin prick

Blood

Neither

Upload prior allergy results if available

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Currently on antihistamines, steroids, or biologics?

History of anaphylaxis or epinephrine use?(Required)

Yes

Sleep Health

Sleep-related symptoms(Required)

Difficulty falling or staying asleep

Wake up unrefreshed despite a full night's sleep

Excessively tired or drowsy during the day

Fall asleep easily during quiet activities (TV, reading, riding in a car)

Snore loudly / told I stop breathing during sleep

Wake with headaches or dry/sore throat

Restless legs or kick during sleep

None of the above

Do any of the following apply?(Required)

Treated for high blood pressure or diabetes

Told overweight or at risk

Grind teeth at night

Prior sleep-disorder diagnosis

Prior sleep study

Wear a sleep apnea device

None

How much is sleep quality affecting your daily life?(Required)

Significantly

Somewhat

Minimally

Not affecting

Has a partner observed you stop breathing?(Required)

Yes

Not sure

Prior sleep study details

Currently using CPAP / BiPAP / oral appliance?

Vein Health & Circulation

Are you experiencing any of the following leg symptoms?(Required)

When do leg symptoms feel worse?(Required)

Standing

Sitting

End of day

At night

During or after exercise

Improve with elevation

N/A

Do any of the following apply?(Required)

Family history of vein disease

Job standing or sitting

History of pregnancy

Prior leg injury, surgery, or clot

Overweight or recent gain

History of leg swelling

Told I have circulation issues

None

How much do leg symptoms affect daily life?(Required)

Mild

Moderate

Severe

Not applicable

Prior vein procedure(Required)

Sclerotherapy

Ablation

Vein stripping

None

DVT or PE history

Currently on blood thinners?(Required)

Eliquis

Xarelto

Coumadin

Aspirin

Other

None

Physical Exam

Reason for the physical(Required)

Last physical date and provider

Specific concerns for this physical

Physical add-ons interested in(Required)

Body composition (SECA)

Micronutrient panel

Hormone panel

None

MRI Review

Body part imaged

MRI facility

Has another provider reviewed it? Who?

Questions you want answered

Date of MRI

Upload MRI report

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Upload images / disc info if available

Pre-Op / Post-Op

What surgery?

Surgeon

Surgery date

Pre-op clearance or post-op follow-up?(Required)

Pre-op

Post-op

Not applicable

What week post-op are you?(Required)

Upload op report or surgeon notes if available

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Workers' Comp / Auto (PIP) Injury

Date of injury

Type

Claim # / Adjuster name / Adjuster phone

Body parts injured

Neck

Back

Shoulder

Knee

Foot-Ankle

Head

Multiple

Other

None

Seen elsewhere for this injury? Facility + provider

Upload police/accident report, MRI, or prior records

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Billing details

Carrier, adjuster, claim #, phone, date of injury, attorney info

Medical History

Drug allergies and reactions(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)

Any reaction to anesthesia or contrast dye?(Required)

Yes

Past / current conditions(Required)

Family history(Required)

Social history(Required)

Female patients only - pregnancy, nursing, LMP, menopause, birth control

Smoking, Vaping & Exposure History

Current smoking history?(Required)

Yes

Former smoking history?(Required)

Yes

Vaping history?(Required)

Yes

Secondhand smoke exposure?(Required)

Yes

Family history of emphysema?(Required)

Yes

Family history of lung cancer?(Required)

Yes

9/11 or occupational dust/smoke exposure?(Required)

Yes

COVID history?(Required)

Yes

Additional smoking/vaping/exposure/COVID details

Dates, duration, amount, quit date

Wellness Screeners

PHQ-9 (Depression)

Little interest or pleasure in doing things(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Feeling down, depressed, or hopeless(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Trouble falling or staying asleep, or sleeping too much(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Feeling tired or having little energy(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Poor appetite or overeating(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Feeling bad about yourself - or that you are a failure or have let yourself or your family down(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Trouble concentrating on things, such as reading the newspaper or watching television(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Thoughts that you would be better off dead, or of hurting yourself in some way(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

GAD-7 (Anxiety)

Feeling nervous, anxious, or on edge(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Not being able to stop or control worrying(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Worrying too much about different things(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Trouble relaxing(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Being so restless that it is hard to sit still(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Becoming easily annoyed or irritable(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Feeling afraid as if something awful might happen(Required)

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Alcohol Use (AUDIT-C)

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2-4 times a month

2+ times a week

How many standard drinks containing alcohol do you have on a typical day when drinking?(Required)

1 or 2

3 or 4

5 or 6

7 to 9 (3 pts) / 10+ (4 pts)

How often do you have six or more drinks on one occasion?(Required)

Never

Less than monthly

Monthly

Weekly / Daily (3-4 pts)

Drug Use (DAST-10)

Have you used drugs other than those required for medical reasons?(Required)

Yes

Do you abuse more than one drug at a time?(Required)

Yes

Are you always able to stop using drugs when you want to? (No = 1 point)(Required)

Yes

Have you had 'blackouts' or 'flashbacks' as a result of drug use?(Required)

Yes

Do you ever feel bad or guilty about your drug use?(Required)

Yes

Does your spouse (or parents) ever complain about your involvement with drugs?(Required)

Yes

Have you neglected your family because of your use of drugs?(Required)

Yes

Have you engaged in illegal activities in order to obtain drugs?(Required)

Yes

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?(Required)

Yes

Have you had medical problems as a result of your drug use (memory loss, hepatitis, convulsions, bleeding)?(Required)

Yes

Emergency Contact & Consent

Emergency Contact Name(Required)

First Last

Emergency Contact Relationship(Required)

Emergency Contact Mobile / Home Phone(Required)

Emergency Contact Email(Required)

HIPAA Notice of Privacy Practices(Required)

I acknowledge receipt of the HIPAA Notice of Privacy Practices

Consent to Treat / Financial Responsibility(Required)

I acknowledge consent to treat and financial responsibility

Communication preferences(Required)

OK to text

OK to email

OK to leave voicemail

None

Photo / Video Consent

I consent to photo/video use as applicable

Scheduling Preferences

Preferred day(s)(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

None

Preferred time of day(Required)

Morning

Mid-day

Afternoon

Evening

None

In-person or telehealth eligible?(Required)

In-person

Telehealth

How quickly do you need to be seen?(Required)

Same day

This week

Next 2 weeks

Flexible

Insurance & Pharmacy

Primary Insurance - Holder Name

Relationship to holder(Required)

Self

Spouse

Parent

Not applicable

Insurance Company / Carrier(Required)

Member ID(Required)

Group #

Insurance Phone

Upload Insurance Card FRONT(Required)

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Upload Insurance Card BACK(Required)

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Upload Driver's License(Required)

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Upload Rx Card if separate

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 220 MB.

Secondary insurance that may cover copays/coinsurance/deductibles?(Required)

Yes

Not sure

Does spouse/partner have a different plan?(Required)

Yes

N/A

Do you have an HSA or FSA card?(Required)

Yes

Not sure

Preferred Pharmacy - name / phone / full address

Specialty pharmacy?

Yes

Different specialty pharmacy for specific meds?

Mail-order pharmacy?

Quick Identity & Routing

Full Name(Required)

First Last

Date of Birth(Required)

Best Phone(Required)

Email(Required)

Address (if changed)

Street Address Address Line 2 City State ZIP Code

Preferred contact method(Required)

Call

Text

Any

Are you returning for the same concern or something new?(Required)

Same issue as last visit

New concern

Both

Which provider or service did you last see us for?(Required)

Other provider or service

What's Changed Since Your Last Visit

Any new injuries, surgeries, hospitalizations, or ER visits?(Required)

Yes

If yes, please describe

New diagnoses from another provider?(Required)

Yes

If yes, please describe

Changes to your medications, supplements, or vitamins?(Required)

Yes

If yes, please describe

Any new drug allergies or reactions?(Required)

Yes

If yes, please describe

Seen any new specialists or started care with a new provider?(Required)

Yes

If yes, please describe

Insurance / Administrative Updates

Has your insurance carrier, member ID, or employer changed?(Required)

Yes

Has your home address or phone number changed?(Required)

Yes

Has your emergency contact information changed?(Required)

Yes

Has your pharmacy changed?(Required)

Yes

Updated administrative details

Reason for Return

What is your #1 goal for this visit?(Required)

Is there anything specific you want to make sure we address at this appointment?

How would you rate your original concern today vs. when you first started care?(Required)

1 = Same/Worse, 10 = Fully resolved

Is there anything we recommended last time that you have not started yet?(Required)

Physical therapy plan or home exercise program

Follow-up imaging (X-ray, MRI, ultrasound)

Regenerative series (PRP, viscosupplementation)

Labs or diagnostic testing

Athletic recovery / ARC sessions

Referral to another provider

None - I completed everything

Other

Other recommended item not started

Services You Haven't Tried Yet

Joint pain, muscle soreness, or mobility issues not yet addressed

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Medical weight loss or GLP-1 options

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Hormonal symptoms - fatigue, low libido, mood changes, menopause

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

IV therapy or wellness infusions

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Sleep concerns - trouble falling/staying asleep, feeling unrested

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Allergy symptoms - seasonal, year-round, or food-related / SLIT

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Athletic recovery / ARC (compression, NormaTec, muscle recovery)

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Leg heaviness, swelling, varicose veins, or circulation concerns

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Preventive care, lab work, or a comprehensive physical

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Aesthetic or wellness services (Medical Botox, etc.)

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Lifestyle & Performance Snapshot

Current activity level / sport / training load

Current goals

Return to sport / athletic performance

Pain-free daily life

Weight loss / body composition

Hormone optimization / energy

General wellness & prevention

Other

Other current goal

Sleep quality(Required)

None

Mild concern

Significant concern - I'd like to discuss

Energy levels / fatigue(Required)

None

Mild concern

Significant concern - I'd like to discuss

Stress / mental wellness(Required)

None

Mild concern

Significant concern - I'd like to discuss

Wellness Check

How would you rate your overall health since your last visit with us?(Required)

Much better

Somewhat better

About the same

Somewhat worse

Much worse

Is there anything you feel has been overlooked, or that you have not had a chance to discuss with your provider?

Logistics & Consent

If you had a gap in care, what was the primary reason?

Scheduling / availability

Cost or insurance coverage

Felt better and stopped coming

Life changes (work, travel, family)

Didn't feel I was getting results

Didn't know we offered what I needed

Prefer not to say

Other

N/A

Day preference(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Time preference(Required)

Morning (8-11am)

Midday (11am-2pm)

Afternoon (2-5pm)

Any

HIPAA Authorization / Notice of Privacy Practices(Required)

Still on file

Need to re-sign

Financial Policy & Assignment of Benefits(Required)

Still on file

Need to re-sign

Consent for Treatment(Required)

Still on file

Need to re-sign

Confirm Your Info

Full Name(Required)

First Last

Date of Birth(Required)

Best Phone(Required)

Email Address(Required)

Preferred contact method(Required)

Call

Text

Any

Has anything changed since your last visit? Insurance carrier, member ID, or employer(Required)

Yes - updated below

No change

Has anything changed since your last visit? Home address or phone number(Required)

Yes - updated below

No change

Has anything changed since your last visit? Emergency contact(Required)

Yes - updated below

No change

Has anything changed since your last visit? Pharmacy(Required)

Yes - updated below

No change

If anything changed, note it here

Today's Appointment

Primary reason for today's visit(Required)

Current Pain & Symptoms

Are you currently experiencing any pain or discomfort?

How severe is your pain today?

0 = no pain, 10 = worst imaginable

How does this compare to when you first started care with us?

1 = Same or worse, 10 = Fully resolved

Do any of the following apply to you right now?(Required)

Tell us more about your pain or symptoms

What makes it better or worse? Any numbness, tingling, weakness, or instability?

Quick Health Update

Any new injuries, surgeries, hospitalizations, or ER visits since your last visit?(Required)

Yes

If yes, please describe

New diagnoses from another provider?(Required)

Yes

If yes, please describe

Changes to your medications, supplements, or vitamins?(Required)

Yes

If yes, please describe

Any new drug allergies or reactions?(Required)

Yes

If yes, please describe

Anything your provider recommended last visit that you have not started yet?(Required)

Physical therapy plan or home exercise program

Follow-up imaging (X-ray, MRI, ultrasound)

Regenerative series (PRP, viscosupplementation)

Labs or diagnostic testing

Athletic recovery / ARC sessions

Referral to another provider

None - I completed everything recommended

Other

Other Services You'd Like to Explore

Joint pain, soreness, or mobility issues not yet addressed

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Medical weight loss / GLP-1 options

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Hormonal symptoms - fatigue, low libido, mood, menopause, ED

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

IV therapy or wellness infusions

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Sleep concerns - trouble falling/staying asleep, feeling unrested

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Allergy symptoms - seasonal, year-round, or food-related / SLIT

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Athletic recovery / ARC (compression, NormaTec, muscle recovery)

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Leg heaviness, swelling, varicose veins, or circulation concerns

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Preventive care, lab work, or a comprehensive physical

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Aesthetic or wellness services (Medical Botox, etc.)

Interested

Already being treated

Already on a plan

Already receiving

Already scheduled

Not interested

Cryotherapy, Infrared Sauna, Salt Room, or Protein Bar

Very interested

Somewhat interested

Not right now

Quick Wellness Snapshot

Sleep quality(Required)

No concerns

Mild concern

Significant - I'd like to discuss

Energy levels / fatigue(Required)

No concerns

Mild concern

Significant - I'd like to discuss

Stress / mental wellness(Required)

No concerns

Mild concern

Significant - I'd like to discuss

Weight / body composition(Required)

No concerns

Mild concern

Significant - I'd like to discuss

Is there anything you feel has been overlooked, or have not had a chance to bring up with your provider?

Scheduling & Consent

Preferred appointment days(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred time of day(Required)

Morning (7:30-11am)

Midday (11am-2pm)

Afternoon (2-5pm)

Evening

Any

How quickly do you need to be seen?(Required)

Same day / ASAP

This week

Next 2 weeks

Flexible

If you had a gap in care, what was the main reason?

Scheduling / availability

Cost or insurance coverage

Felt better and stopped

Life changes (work, travel, family)

Didn't feel I was getting results

Prefer not to say

N/A - I haven't had a gap

HIPAA Authorization / Notice of Privacy Practices(Required)

Still on file

Need to re-sign

Financial Policy & Assignment of Benefits(Required)

Still on file

Need to re-sign

Consent for Treatment(Required)

Still on file

Need to re-sign

Final Consent & Signature

Consent to Treat form

I have read and agree to the Consent to Treat form(Required)

Yes

Signature(Required)

Chiropractic Care

Chiropractic Care

Pain Management

Pain Management

Physical Therapy

Physical Therapy

Acupuncture

Acupuncture

Podiatry

Podiatry

IV Therapy & Infusions

IV Therapy & Infusions

Hormone Optimization

Hormone Optimization

Regenerative Medicine

Regenerative Medicine

Allergy & SLIT

Allergy & SLIT

Weight Management

Weight Management

Sleep Studies

Sleep Studies

Athletic Recovery

Athletic Recovery

Chiropractic Care

Chiropractic Care

Pain Management

Pain Management

Physical Therapy

Physical Therapy

Acupuncture

Acupuncture

Podiatry

Podiatry

IV Therapy & Infusions

IV Therapy & Infusions

Hormone Optimization

Hormone Optimization

Regenerative Medicine

Regenerative Medicine

Allergy & SLIT

Allergy & SLIT

Weight Management

Weight Management

Sleep Studies

Sleep Studies

Athletic Recovery

Athletic Recovery

Schedule Appointment

Contact Us

Request an Appointment

Patient Type

About You

What Brings You In?

Pain, Musculoskeletal, and Recovery

Primary Care / Sick Visit

Hormone / HRT

Medical Weight Loss

IV Therapy

Allergy / SLIT

Sleep Health

Vein Health & Circulation

Physical Exam

MRI Review

Pre-Op / Post-Op

Workers' Comp / Auto (PIP) Injury

Medical History

Smoking, Vaping & Exposure History

Wellness Screeners

PHQ-9 (Depression)

GAD-7 (Anxiety)

Alcohol Use (AUDIT-C)

Drug Use (DAST-10)

Emergency Contact & Consent

Scheduling Preferences

Insurance & Pharmacy

Quick Identity & Routing

What's Changed Since Your Last Visit

Insurance / Administrative Updates

Reason for Return