About
Services
ThermiVa®
ThermiSmooth®
Intake Form
CoolSculpt
Contact
About
Services
ThermiVa®
ThermiSmooth®
Intake Form
CoolSculpt
Gaia ~ the goddess of the earth
Contact
Patient Intake Form
Schedule an Appointment
Call
(978) 739-1400
Please complete our intake form below prior to visiting the office.
Today's Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Email Address
Street Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
(###)
###
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Other Phone
(###)
###
####
Place of Employment
*
Referring Physician
Primary Care Physician
Emergency Contact
Emergency Contact Phone
(###)
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Pharmacy Name
Pharmacy Phone
(###)
###
####
INSURANCE INFORMATION
Name of Subscriber
*
Subscriber Date of Birth
MM
DD
YYYY
Place of Employment of Policy Holder
Primary Insurance Coverage
Policy #
Secondary Insurance Coverage
Policy #
PLEASE PRESENT ALL INSURANCE CARDS TO THE RECEPTIONIST.
If your insurance requires a referral before receiving services, it is your responsibility to obtain a referral from your primary care physician. Otherwise, you will be directly responsible for all the charges at the time of service.
INSURANCE AUTHORIZATION AND ASSIGNMENT
*
I authorize Dr. Pursell to furnish information to insurance carriers and other physicians concerning my condition and/or treatment. I also authorize and assign Dr. Pursell all payment for medical services provided to my dependents and myself. I understand that I am responsible for any charges not covered by my insurance company.
Yes
No
Patient Signature
Date
MM
DD
YYYY
TO ALL OUR PATIENTS
All personal and health-related information that you make available to us is used exclusively for the purpose of providing you with the medical care that you require and for the purposes of billing your insurance carrier(s) for the care we provide. Great care is taken to maintain the confidentiality of your personal information. Please take the time to review and complete this form, which will assist our office in maintaining the privacy of your health-related information. Circle YES or NO for each of the questions below and put your initials next to them and sign the bottom of this form. We will update this form on an annual basis. If you wish to change anything prior to that time, you are welcome to request a new form from our office any time. Thank you.
1. Is it OK to leave a message for you at your home telephone number on voice mail or an answering machine?
*
Yes
No
2. Is it OK to leave a message for you at your home with your spouse?
*
Yes
No
3. Is it OK to leave a message for you at your home with a member of your household other than your spouse?
*
Yes
No
4. Is it OK to leave a message for you to call our office at your work place?
*
Yes
No
5. Is it OK to discuss your medical history with your spouse?
*
Yes
No
Please list anyone else with whom you authorize us to discuss your medical history or condition, if necessary (i.e. children, close friend, clergy member, etc.).
Patient Signature
*
Date
*
MM
DD
YYYY
Thank you for your submission. We look forward to seeing you soon!
