New Patient Form – ScoliCare Naples Florida

New Patient Form

Fill out your information below:

Patient's Information

Title

Marital Status

Patient First Name

Patient Last Name

Patient's Date of Birth

Date format: mm/dd/yyyy

Street

City

Postal Code

Country

State

Primary Contact Number

Primary Contact Role

Secondary Contact Number

Secondary Contact Role

Occupation

Emergency Contact Name

Emergency Contact Phone Number

How did you hear about us?

Other

I agree to receive SMS messages from ScoliCare regarding my enquiry, consultation scheduling, appointments, services, treatment updates, and other relevant communications. Message and data rates may apply. Message frequency varies. Carriers are not liable for delayed or undelivered messages. Reply HELP for assistance & STOP to opt out. View our Privacy Policy and Terms & Conditions.

Referring Health Professional Details

I have been referred by a Healthcare Professional

First Name

Last Name

Clinic Name

Phone

Country

State

Occupation

Other occupation

PATIENT PRIVACY POLICY:

I acknowledge and accept the terms of the patient privacy policy.

CONSENT TO EXAMINATION:

The Clinician will discuss your health concerns and carry out an examination of posture, spine and other related body areas.

Postural photos will be taken.

Minimal clothing such as a sports bra and shorts will need to be worn.

X-ray may be used to aid diagnosis and monitor treatment progress.

I agree to this examination for myself / my child.

FINANCIAL CONSENT AND PAYMENT POLICIES:

I hereby authorize payment to be made directly to ScoliCare, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to ScoliCare for any and all services I receive at this office.

Payment for services and products is due on the day of your appointment. The initial consultation fee is $325.

I acknowledge that I am responsible for these payments.

MEDIA RELEASE CONSENT (Optional):

I hereby give ScoliCare the irrevocable right and permission to use photographs and/or video recordings of me on Social Media, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me. I understand and agree that such photographs and/or video recordings of me may be placed on the Internet for the purposes of promoting specific results. I also understand that any use of my name and or video and pictures will be at my discretion and can only be shared with permission.

I agree and fully understand the above statements.

PATIENT NEWSLETTER AND OTHER INFORMATION:

We occasionally send emails about scoliosis and kyphosis related news, research, clinic and service updates and events. This includes our quarterly newsletter designed specifically for ScoliCare patients. Let us know below if you would like to get this information delivered straight to your inbox.

Please send me email updates on scoliosis related news and information, including education research and events.