Dr. Mark Brandwein
611 Broadway Rm 907C New York, NY 10012 | sohochiro@aol.com
 
 
 
 
 
Call Us for a Free Consultation!
 
 
 
 
 
 
 

Scheduling Your Appointment With Soho Chiropractic in New York, NY

Patient Information

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the Submit button at the bottom of this form.
 

Personal Information

 
Gender:
 
 
 
Married/Civil Union:
 
 

Contact Information

Address

How did you find out about our office?

 
Did you hear about our office from an advertisement?
 
 
 
 
 
 
 
 
 
What is the purpose of your visit?
 
 

Current Complaints

 
Where did the injury occur?
 
 
 
Date of Injury
 
 
 
Select frequency you experience pain from this condition
 
 
 
 
 
 
 
 
 
 
 
 
Have you missed any work due to this injury?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Insurance & Payment for Care

 
How do you plan to pay for care?
 
 
 

Primary Insurance

 
Address
 

Secondary Insurance

 
Address
 

Personal Health History

Please list any health conditions that you have been treated for in the last year:
(condition, cause, current/resolved)
 
 
 
List current medications:
(name, amounts, frequency, length of use, reason for use)
List current vitamins, minerals, supplements, or herbs:
(name, amounts, frequency, length of use, reason for use)

Family Health History

Please list diagnosed health conditions and untimely deaths of your blood-related family members.
(condition, relationship to you)
Separate details with "," comma as shown above.

 

Health Problems & Concerns

Please select all that you have had or currently have.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Authorization

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic.

I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.