Patient first name:

 Patient last name:

DOB:

Address:

Primary Phone Number:

You may complete the sentence by typing in the radiation text box...
ie. The Cervical Compression Test was positive on the left... you may want to enter in the radiation box... with pain produced into the left shoulder and radiating down to the elbow.
The output in the narrative will read
The Cervical Compression Test was positive on the left with pain produced into the left shoulder and radiating down to the elbow.

Health Insurance Company

Cash (no health insurance) AETNA AMERICAN SPECIALTY HEALTH NETWORK (ASHN) Blue Cross/ Blue Shield OF OREGON BlueCard: Premera BC/BS OUT OF STATE BC/BS FEDERAL EMPLOYEE PROGRAM CIGNA Empire blue cross FIRST HEALTH First Choice Health GREATWEST HEALTHCARE Healthcare Management Administrators HEALTHNET OF OREGON HEALTHWAYS Intergrated Health KAISER LIFEWISE OF OREGON MAILHANDLERS MEDICARE MULTIPLAN ODS PACIFICARE PACIFICSOURCE PRIVATE HEALTH CARE SYSTEMS (PHCS PRINCIPAL INS CO. PROVIDENCE PROVIDENCE MCO (workers comp) Reliant Behavioral Health SCHOOL DISTRICT Saif UNITED HEALTHCARE

Insurance / Subscriber # Group # Primary name on insurance (type NA if no insurance)

Employer

Email (required with your permission we will email treatment plan, home exercises, & diagnosis of your 1st visit)

Height Weight

Date:Sunday May 20, 2012

Enter Date for initial appointment:

Comments and/or Questions