Patient Intake form

Patient Intake Form - Rockford, IL

If you are not currently a patient, please call to schedule an appointment before filling out this form.

All new patients must complete the following intake form and Body Scan Tool Consultation Request form prior to their appointment. Link to the Body Scan tool form can be found on the Patient Forms page.

Today's Date

First Name

Last Name

DOB

Phone

Address

City

State

Zip

Emergency Contact

Phone

Relationship

Occupation

Referred By:

Health Information (Check all that apply)

Notes

Any current infectious or contagious conditions? (e.g. HIV, TB, fungal infections, shingles, warts, etc.) If yes, please list:

Are you taking any medications / supplements? If yes, please list:

Do you have any allergies or hypersensitivities? (oils, lotions, nuts, fruits, skin, etc.) If yes, please list:

Are you pregnant? If yes, please indicate how far along you are and your due date.

History of joint replacement surgery? If yes, which joint(s)?

Any implants? If yes, lease list the type of implants and where it is located. (e.g. pacemaker, insulin pump, metal, etc)

If you are currently under medical supervision or receiving other medical interventions, please describe.

Please describe any recent injuries or medical procedures in the past 2 years.

Please describe any other injuries or health conditions, not previously indicated.

Cancelation Policy:

We are dedicated in assisting you to meet your treatment goals. For us to help you achieve these goals, it is important that you attend your scheduled appointments consistent attendance allows you and your providers the ability to progress your treatment program which will result in a quicker recovery and most importantly, help you feel better.

We do require that you give us at least a 24‐hour notice that you will be unable to make it to an appointment. We do realize that there are times when unexpected circumstances make it difficult to attend your scheduled appointments. We just ask you give us as much notice as possible. This is so we can reschedule you for a better time, as well as, opening that spot for another patient. Cancelling an appointment with short notice or no notice takes up valuable clinic time that could benefit another patient waiting for treatment.

In order to enforce this policy, your credit card on file and/or your account will be charged for any same day cancelation or no show/no call appointment fees. For a SAME DAY CANCELATION a patient(s) will be charged a $35 fee per missed appointment slot. For SAME DAY CANCELATION appointments scheduled for longer than 1 hour an additional $35 fee may apply. Meaning, if you have a 90‐minute appointment or 2‐ hour appointment your card will be charged $70, for the same day cancelation fee. For any appointment that is missed as a NO CALL / NO SHOW, the patient(s) is responsible for the full cost of the service(s), with a MINIMUM fee starting at $35. ALL fees must be paid prior to making any future appointments.

Please be advised your insurance will NOT cover charges for late cancellations or no‐shows. It is the patient’s responsibility. Also, please note that “No‐shows” or cancelling appointments without a 24‐hour notice more than three times will unfortunately limit your ability to schedule advanced appointments and will result in scheduling same day only.

We want to make your rehabilitation experience as beneficial to you as possible. Your commitment and attendance are very important in achieving this. If you know ahead of time you will have difficulty making your appointment, please discuss this with the doctor or therapist. We will try our best to accommodate you and your needs.

I have read the above cancelation policy and understand my potential financial responsibility for non‐compliance.

Non-Solicitation Agreement:

I acknowledge that I am not allowed to solicit or hire any individual staff member or entity from within Circle of Wellness, and by doing so is a direct breach of all staff members employee contract. I acknowledge that I am not allowed to accept solicitation from any individual staff member or entity outside of Circle of Wellness, and by doing so is a direct breach of all staff members employee contract. I acknowledge that any breach of employee contracts will result in legal action being taken against either or both parties. I acknowledge this Non-Solicitation Agreement and agree to abide by the Agreement.

I have read the above non-solicitation agreement and understand my potentiall responsibility for non‐compliance.

Individual 1 Name

Individual 1 DOB

Individual 1 Relationship to Patient

Individual 2 Name

Individual 2 DOB

Individual 2 Relationship to Patient

Individual 3 Name

Individual 3 DOB

Individual 3 Relationship to Patient

I give permission for the following things to be discussed with the individuals listed above (Please check all that apply)

Consent to Treatment

By checking this box and entering my name below in the signature field, I acknowledge that I am aware of the benefits and risks of any therapies I may receive at Circle of Wellness and that I have completed this form accurately and truthfully to the best of my knowledge. I also agree to inform staff of any health or medical changes.

Patient Name (signature)

Consent to Treatment of a Minor

Consent to Treatment of a Minor (under the age of 18): By clicking this box and entering my name below I hereby authorize Circle of Wellness to provide therapy to my child or dependent as deemed necessary.

Guardian Name

New Patient Intake Form – Rockford, IL

Patient Intake form