We would like to welcome you to our practice and ask that you kindly complete all information listed. PATIENT INFORMATIONDate Completed* Date Format: MM slash DD slash YYYY Name* First Name Last Name Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail* Social Security Number*Marital Status*SingleMarriedDivorcedWidowedEmployer NameEmployer Phone NumberHow Did You Hear About Us?Primary / Family DoctorDoctor's PhoneEMERGENCY CONTACTEmergency Contact NameRelationshipPhone NumberPRIMARY MEDICAL INSURANCECompanyMember IDGroup NumberSubscriberDate of Birth Date Format: MM slash DD slash YYYY SSN Date Format: MM slash DD slash YYYY Relationship to PatientSelfSpouseParentSECONDARY MEDICAL INSURANCECompanyMember IDGroup NumberSubscriberDate of Birth Date Format: MM slash DD slash YYYY SSN Date Format: MM slash DD slash YYYY Relationship to PatientSelfSpouseParentCURRENT HEALTH CONDITIONOverall HealthExcellentGoodFairPoorChief ComplaintPlease briefly describe the reason you are hereHave you seen another doctor for this conditionYesNoWHO DID YOU SEE?TYPE OF TREATMENTWHEN DID THIS CONDITION BEGIN?RESULTSMEDICAL HISTORYPlease select the conditions that you have been diagnosed with. Rheumatic Fever Gall Blader Disease Heart Murmur Blood Clots Stroke Arthritis High Blood Pressure Anemia Elevated Cholesterol Cancer Varicose Veins Pneumonia Tuberculosis Broken Bones Kidney/Bladder Infection Diabetes Epilepsy/Seizure Stomach Ulcers Bronchitis or Asthma Thyroid Disease Emphysema Colon Disease Head/Spine Trauma Hepatitis Sports Related Injury Joint Disease HIV Please list any surgical procedures you have undergonePlease list any surgical procedures you have undergonePROCEDUREDATEHOSPITAL Please list any medications you are currently taking including frequency and dosage:Please list any allergies including drug allergies you haveFAMILY HISTORYRelationship, Age, Health ProblemsPlease list family history according to the format aboveListRELATIONSHIPAGEHEALTH PROBLEMS SOCIAL HISTORYPlease check all that apply Alcohol Drugs Tobacco/Cigarette Coffee Tea Soft Drinks Please Note: Any Medical Emergencies - Please call 911 or Go to the Nearest Emergency RoomFINANCIAL DISCLOSURE At Delaware Integrative Medicine, we have partnered with a few insurance companies in an attempt to lessen the financial burden on our patients. The insurance companies we partner with, typically cover office visits, technical fees involving injection, IV and Ultrasound tests. Most insurance companies do not cover expenses related to the administration of therapies used here to treat you including: ozone; UBI; PEMF; FSM; IV therapies (Myers, MAH, Glutathione, Chelation); saunas, etc. You are responsible for any our-of-pocket expenses not covered by your insurance. If you do not have insurance, you are responsible for all fees including office visits and any additional fees. If you default on any payment due, your account will be turned over to our collection agency. You are responsible for any fees or court costs as a result of our collection efforts. Late fee, charge and interest can be 18-24% as allowed by lawAGREEMENT* Click here to indicate that you have read and agree to the terms presented above. Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.