Wayne Neurology - Publicforms

Available Forms

EEG Information Sheet and preparation guidelines EMG Information Sheet and preparation guidelines Evoked Potentials Auditory (AEP), Visual (VEP), Upper (SEP) New Patient Registration VNG Videonystagmography

New Patient Registration

Please fill out the New Patient registration form to the best of your ability and as complete as possible. If you are having problems filling out these forms, please contact out office at (734) 721-4739. If it is after hours please leave a message and a receptionist will contact you the following business day.

Patient Information

Patient Name *

Enter Last, First and Middle Initial

Patient Date of Birth *

Gender *

Male

Female

Patient Social Security Number

This Field is not required at this time, you may wait until day of visit to inform office staff of this information.<br/>

Street Address *

City *

State *

Zip Code *

Whom May We Contact in the Case of an Emergency?

Last Name, First Name, Telephone Number, Relationship to Patient

Enter the First and Last name of the Patients Primary Care Physician

Patient Insurance Information

Primary Insurance Company *

Please Enter Insurance Name

Contract Number

Group Number

Insurance Group Number

Policy Number

Subscriber

Subscriber DOB

Is there a Secondary Insurance *

Yes

Secondary Insurance Company

Contract Number

Group Number

Policy Number

Subscriber

Subscriber DOB

Other Insurance (Workman's Compensation/ Auto Accident)

Insurance Company

Claim Adjuster

Address

City

State

Zip

Phone Number

Claim Number

Medical Information

Main Reason for Visit *

Is the patient condition related to: *

Employment

Auto Accident

Other

None

If Employment or Auto Accident please indicate the date of the incident

What Treatment Have You Already Received? *

Please List if Any X-Rays, MRIs, EEGs, VNG, EMG, BAER, SEP, VER, CT Scan, Blood Test, and Where They have Been Done at.

Please List all Present Medications *

Please Include Name, Dose, and Frequency

Please Briefly List Past Medical History *

Please Briefly List Family Medical History *

Has the Patient Ever Been Hospitalized *

Yes

Does the Patient have any Known Drug Allergies *

Yes

No Known Drug Allergies

If Yes Please List all Drug allergies

Review of System

Do You Have? *

Please Select Your Review of System

Please Indicate Your Current Level of Pain *

Does Your Pain Disturb Your Sleep? *

Yes

What Makes Your Symptoms Worse

Patient Employment Information

What is the Patient Employment Statues *

Employed

Unemployed

Student

Retired

Other/Not Listed

If Currently Employed Please Indicate Employment Information

Name of Employer, Phone Number and Job Title

Release of Information

Is there someone we have permission to contact or share medical information with on the patients behalf? *

Yes

If Yes please document Last Name, First Name, Relationship to patient, Date of Birth and Telephone Number

Please List all Doctors, Attorneys, and Case Managers Patient would like Records Released to

Please Include First and Last Name

Social History

Does the Patient Smoke or use Tobacco *

Yes

Sometimes

Former Smoker

How Often Does the Patient Drink Alcohol *

Daily

Weekly

Monthly

Occasionally

Rarely

Never

Please List any Recreational Drugs the Patient has Take if Any If None Please Write None *

How Many Days a Week Does the Patient Typically get at Least 30 Minutes of Moderate Exercise

Miscellaneous Information

How did the Patient hear about our office *

Race *

Asian

Black or African American

Black Hispanic or Latino

Native Hawaiian and Other Pacific Islands

White

White Hispanic or Latino

Refused

Unknown

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Language Preference *

After completing the above form please click submit, once received someone from our office will send you the rest of the office forms to your patient portal. If you are able to print the forms and sign them please bring them in along with your ID and Insurance card. If you are unable to print these forms, we will give you a copy of all the forms at your visit.

* Required field