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Convenient Downtown NYC Location

139 Fulton Street, Suite 136
New York, NY 10038

The First Step For New Patients is Evaluation

We need to know your condition and what discomforts you are experiencing so that we may treat you with the proper therapies.

The new patient evaluation starts with filling out a form, and then a meeting with the doctor. The doctor will conduct various tests to ascertain soreness, sensitivity, and range of motion.

The doctor will also discuss some of your responses on this form.

All new patients are required to fill out this form prior to examination. Online completion of the form will eliminate the need to do so in our waiting room on your first visit.

Please complete this form so that we can provide you the best possible wellness care.

The doctor will review your information during your initial visit and discuss your responses.

This form is required and will help ensure that none of your symptoms are overlooked.

Your responses on this online form are encrypted, and safe from view by anyone but the doctor.

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

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