New Patient Intake Form

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Today’s Date: ____/____/______

Patient Name: __________________________¬¬¬________________ Date of Birth: ______/______/_______ Age: __________
Address __________________________________________ City _________________ State ______ Zip Code ____________
Home Phone: ____________________ Work Phone: _____________________ Cell Phone: _____________________
Email: _____________________________________ Sex: 0 Male 0 Female Marital Status: 0 Single 0 Married
Employment Status: 0 Employed 0 Unemployed 0 FT Student 0 PT Student 0 Other____________________
Employer Name: ____________________________________ Occupation: _________________________________________
Employer Address ____________________________________ City ____________________ State_____ Zip Code _________
Primary Care Physician ___________________________________ Phone #: _________________ Last Visit _____________
Emergency Contact Name: _________________________________ Relationship to Patient: __________________________
Emergency Contact Phone #: ____________________________ Alternative phone: ______________________________
Reason for Visit: 0 Non-Surgical Bunion Repair 0 Hair Renewal 0 Non-Surgical Facelift 0 Acupuncture
0Chiropractic 0 Other: ___________________________ How did you hear about us? __________________________
I will be paying by: 0 Cash 0 Credit / Debit card
I have completed and reviewed the above information and to the best of my knowledge it is accurate. I authorize the individual physicians to advise me of any necessary procedures, diagnostic studies and treatment. I will notify you of any changes in my status of the above information.
Patient Signature: Date:
(Patient or Parental Signature if Patient is a Minor)
Medical Conditions (Check all that apply):
0 Arthritis 0 Cancer 0 Diabetes 0 Heart Disease
0 Hypertension 0 Psychiatric Illness 0 Skin Disorder 0 Stroke
0 Headaches 0 Multiple Sclerosis 0 Epilepsy 0 GI
0 Urinary 0 Ears, Nose, Throat 0 Back 0 Neck
0 Other: _________________________________________________________________________
Past Medical History: ______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Surgeries (Please list ALL surgeries and hospitalizations): _________________________________________________________
________________________________________________________________________________________________________
Allergies: ________________________________________________________________________________________________
Social History (Check all that apply):
Caffeine use: 0 Occasional 0 Often 0 Never
Drink Alcohol: 0 Occasional 0 Often 0 Never
Exercise: 0 Occasional 0 Often 0 Never
Cigarettes: 0 <1 pack/day 0 >1 pack/day 0 Never
Family History (Check all that apply):
Arthritis: 0 Parent 0 Sibling
Cancer: 0 Parent 0 Sibling
Diabetes: 0 Parent 0 Sibling
Heart Disease: 0 Parent 0 Sibling
Hypertension: 0 Parent 0 Sibling
Stroke: 0 Parent 0 Sibling
Thyroid: 0 Parent 0 Sibling
Other: ___________________________________________________________________________
Current Medication/Vitamins: _______________________________________________________________________________
_______________________________________________________________________________________________________
Are you pregnant? Yes ______ NO _______ N/A ________
The statements on this form are correct to the best of my recollection. I understand that I am financially responsible for all charges. I understand that Dr. Levingston dos not bill insurance and payment is due at the time of service.

Patient Signature: ______________________________________ Date: ____________________________

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Learn more about our alternative bunion treatment. Start your consultation today. Call us at 303-532-4844, or use our consultation form shown below to send us information and pictures. You can also request a Free Report.