Patient Information

Name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Mobile Phone

(###)

###

####

Status

Divorced

Married

Other

Separated

Single

Widowed

Number of Children

Emergency Contact

Name

First Name

Last Name

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Mobile Phone

(###)

###

####

Insurance Information

Name of Policyholder

Name of Insurance Company

Insurance ID

Insurance Phone Number

(###)

###

####

Employer Information

Name of Employer

Job Title & Description

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Presently Working

Yes

Past Medical History

Previous Injuries

Major Accident/Falls

Hospital/Surgery

Illness/Disease

Medications

Family History

Mother

Father

Brother

Sister

Attorney Information

Name of Attorney

First Name

Last Name

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Assignment of Benefits

I authorize payment of medical benefits to Restore353, located at 353 Lexington Ave., Ste. 1001, New York, NY 10016. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him/her for service rendered me and that this agreement is made solely for said doctor's additional payments protection and in consideration of his awaiting payments.

Authorization For The Release of Medical Records

Kindly furnish my insurance company or their representative all information you may have regarding my condition while under your treatment or observation including the history obtained, x-ray and physical findings, diagnosis and prognosis. You are authorized to provide this information in accordance with the New York State Workers' Compensation and other applicable leave.

Verification of Non-Pregnancy

I am not pregnant at this time.

Date of Last Menstruation

YYYY

Acknowledgement of Testing if Medically Necessary

I understand that there are certain tests that the physician may need to perform in his/her course of treatment. I acknowledge that the physician may make certain fees based on these tests. I understand and acknowledge that it is my choice as to whether I choose this physician to conduct the tests or I may choose to have a different physician perform the requisite tests.

Authorization of Direct Payment From Insurance Company to Restore353

I understand and agree that any payments that I received from my insurance company will be forward directly to Restore353.

I understand and agree that I am totally responsible for payment of any outstanding balance on my account.

Credit Card Information

Credit Card Information Will Be Kept On File. Patient Will Not Be Charged Upon Submitting The Patient Intake Form. Please Read Our 24 Hour Appointment Cancellation Policy And Self-Pay Patient Payment Agreement Below. Thank You.

Name on Card

First Name

Last Name

Credit Card Number

CVV

Expiration Date

YYYY

24 Hour Appointment Cancellation Policy

Restore353 has a 24 hour cancellation/rescheduling policy. If you miss your appointment, cancel or change your appointment within less than 24 hours’ notice, you will be charged $100. This policy is in place out of respect for our therapists and our clients. Cancellations Within less than 24 hours’ notice are difficult to fill and therapists still need to be paid when appointments are cancelled. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot. By checking the box below, you acknowledge that you have read and understand the Cancellation Policy for Restore353 as described above. Thank you for your understanding and cooperation.

Self-Pay Patient Payment Agreement

I have been made aware that my insurance benefits from the Blue Cross Blue Shield/Aetna Insurance are unlimited visits, but these visits are based on medical necessity, and this necessity is determined by the insurance and are reviewable by them at any time.

I am fully aware that I will be responsible for all charges related to the services provided to me by Restore353 in the case that my insurance denies my visits. This includes a post payment audit that can be conducted by Aetna.

I certify that I have read and agreed to the following, received a copy thereof, and I am the patient to execute the above and accept its terms.

Please Continue to our Notice of Privacy Practices and Rights Page to complete your patient intake form.

Thank You!