Outpatient Registration

Medical History

Today's Date (Required)

Email (Required)

Patient Information

Name (Required)

DOB (Required)

Reason For Referral (Required)

Referral Source (Required)

School (Required)

Grade (Required)

Siblings

Medical History

Medical Diagnosis (Required)

Allergies (Required) YesNo

If yes, please list

Are Vaccination Up To Date? (Required) YesNo

If no, please explain

Medications/Supplements

Recent Surgeries

Please Explain If Experienced Any of the Above

Developmental History

Birth Weight (Required)

Birth Height (Required)

Premature? (Required) YesNo

What Age Did Your Child:

Sit Up (Required)

Babble (Required)

Crawl (Required)

Said First Word (Required)

Colored (Required)

Walked (Required)

Dressed Themself (Required)

Toilet Trained (Required)

Fed Themselves (Required)

Patient Authorization Record

Authorization for Treatment
I hereby give authorization for the performance of such rehabilitation procedures as permitted by Advance Wellness and Education Center Statutes under the appropriate scope of practice are, in the judgment of my Therapist, deemed necessary. (Required)

Authorization for Release of Information
I agree that Advance Wellness and Education Center may provide information from my medical record to persons involved in my medical care.
I authorize the release of medical information necessary to obtain payment of any benefits available to me to Advance Wellness and Education Center for services rendered.
I agree that Advance Wellness and Education Center may obtain information from others who have provided medical care to me and/or are responsible for the payment of all or part of my bills when this information is needed in order to treat, bill, and/or receive payment.
I have read “Notice of Privacy Practices” mandated by HIPAA. (Required)

Authorization for Release of Payment
I authorize that direct payment of any benefits available to me be released to Advance Wellness and Education Center for services rendered. (Required)

Patient Agreement
I agree to pay Advance Wellness and Education Center charges for services rendered to me during my course of treatment. I agree to pay those charges which may not be paid by my health insurance and are my responsibility per my insurance benefit. If I do not pay for charges that are my responsibility, I agree to pay Advance Wellness and Education Center collections costs including attorney and court fees. (Required)

By checking this box, I agree to store/save my credit card in Advance Wellness and Education Center's secure credit card payment system and allow my credit card to be billed at the time of service. I agree

Medicare, Medicaid, and Similar Benefits
I agree that the information given to Advance Wellness and Education Center in applying for benefits under Medicare, Medicaid, and Maternal or Child Health services are complete and accurate. I agree that Advance Wellness and Education Center may give Social Security Administration or its fiscal intermediary’s information necessary to process claims. (Required)

Patient Handbook
I have received the Advance Wellness and Education Handbook and the following policies have been reviewed: HIPPA, Conflict Resolution, Mandated Reporters, Cancellation/No Show Policy, Photography Policy, Child Safety Policy and Illness and Safety Policy. I agree to all the policies the handbook contains. (Required)

Photo Release (OPTIONAL)
I agree to allow Advance Wellness and Education Center to photograph or video my child for the purpose of medical charting and documentation of progress.

Please sign here [uacf7_signature* patient-auth-form-sig]

Consent to Email and Text

The Advanced Wellness and Education Center would like to offer you the ability to receive unencrypted emails and text messages. The content received via unencrypted email varies on the services provided to you buy could include: session notes, receipts of payment(s), and surveys. The content received via SMS text message would be in regards to appointments

These text messages and emails should not be solely replied upon. The responsibility of attending and cancelling appointments still rests with you, but we hope this will make it easier.

Please check the box below in regards to SMS text messages.

I ALLOW the Advanced Wellness and Education Center to contact me via SMS text message. I will ensure that I keep the practice informed of my up to date mobile number at all times, or if the number is no longer in my possession. I Allow

I DO NOT ALLOW the Advanced Wellness and Education Center to contact me via SMS text message. I Do Not Allow

Please check the box below in regards to emails.

I ALLOW the Advanced Wellness and Education Center to contact me via email. I will ensure that I keep the practice informed of my up to date email at all times, or if the email is no longer in my possession. I Allow

I DO NOT ALLOW the Advanced Wellness and Education Center to contact me via email. I Do Not Allow

Please sign here [uacf7_signature* auth-email-text-sig]

Outpatient Clinic Registration

Medical History

Patient Authorization Record

Consent to Email and Text

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