New Patient Form

Please complete and submit our online New Patient Package information located below prior to your first appointment. Simply input the information and click next, until prompted to submit. If the information is submitted properly, you will receive on-screen confirmation. Please answer all questions to the best of your ability. All of the information needs to be inputted at one time, so please take a few minutes to complete all of the pages.

If you are unable to complete this information online, please click on this link to download and print a hard copy to fill out and bring to your first appointment.

Step 1 of 8

Health Care Practitioners and Patient Communication
Please provide us with the names and addresses of all of your doctors and health care providers.
Family/Primary Care Physician
Name
First Last
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Family Dentist
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Please add other if relevant.
- Orthodontist
- Oral Surgeon
- Endodontist
Name
Prefix First Last
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Specialty Providers
Do you have a specialty provider you want to add?
- Yes
- No
Specialty
Name
Prefix First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Do you have a second specialty provider you want to add?
- Yes
- No
Specialty
Name
Prefix First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Do you have a third specialty provider you want to add?
- Yes
- No
Specialty
Name
Prefix First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Patient Signature Acknowledgement
By signing here, I am giving my permission to communicate with the above named health care providers regarding my treatment.
Patient Signature Acknowledgement*
First Last
Date*
MM slash DD slash YYYY

Consent Form for Care
I agree to be evaluated and treated at the Head Pain Institute, (herein after referred to as The Practice) by a Practice Provider as deemed medically appropriate. I acknowledge that no procedure will be performed without having been provided appropriate information regarding treatment and possible side effects or consequences. Signing this document implies informed consent on the part of the patient. In this arena, the Practice is released from harm. Although the physician and staff will make efforts to obtain my appropriate medical history and information, the Practice shall not be held responsible for issues of omission or negligence on the part of the patient. I further acknowledge that the Practice is not functioning as my primary care/family physician, and if there are issues dealing with my primary care or internal medicine, they may be referred to my primary care physician by the Practice. There may also be instances where the Physician of the Practice will refer me to additional specialty care and evaluation as needed. As for my responsibility to the Practice, I agree to attend appointments and therapies as scheduled. Multiple missed appointments, or inappropriate behavior may result in termination of services and referral to their physicians. Failure to cancel or no show for appointments will be subject to a charge for that visit. During your therapy, it may become necessary to discuss surgical treatment options if painful or restrictive joint function continues. This may include arthroscopic or open TMJ surgery and/or possible jaw repositioning surgery. A Practice Provider will, if necessary, discuss these options thoroughly. Following initial appliance therapy, there may be decisions to make by the patient and doctor concerning stabilizing or correcting the bite at the natural jaw position, determined by your muscles, if necessary. As joints and muscles relax and heal, there will be changes in your bite (how your teeth come together). Once, it is felt that you have reached your optimum level of improvement, adjusting your bite to your new jaw position may be recommended. As part of your care, you may receive injections of one kind or another. Usually, these are trigger point injections into the motor point of various painful muscles. On occasion, a joint injection will be done. This consent for treatment acknowledges that there can be side effects from any injection. Side effects can include: allergic reactions, localized pain at the injection site or pain along the referral pattern of the nerve or muscle injected. On rare occasions more serious adverse events have been known to occur: fever, infection, muscle and bone atrophy, rash anaphylaxis, pneumothorax, breathing difficulty, sudden changes in blood pressure, convulsions, death. If a procedure is going to be done, a further discussion will ensue, but you are encouraged to ask questions. We wish to empower you to seek a higher level of health by getting involved. HeadacheS, TMJ disorders and sleep apnea are chronic conditions that are managed, not cured; we are not able to guarantee that all patient's condition will improve. Upon rare occasion, condition and symptoms may worsen. We will not be examining your teeth or oral cavity, even though we will be looking in your mouth for other issues. Additionally, we will not be taking x-rays of your teeth. It is your responsibility to have a general dentist examine and maintain your oral health. If you do not have a general dentist, we may be able to recommend one. CT Scans or MRIs may be required to have imaging of the head and neck for diagnostic and treatment purposes. Ultrasound and ICAT units are available on premises or a referral to an imaging center will be made.
Patient Signature Acknowledgement*
First Last
Date*
MM slash DD slash YYYY

Financial Policy
Please be informed that your Insurance Company may not pay for all treatment. We cannot guarantee what services or items will be covered by your insurance. If your Insurance Company does not pay for the services, or items provided, you will be responsible for payment in full. Some services may not be covered by your plan or may not be considered medically necessary. It is your responsibility to check your in-network and out-of-network insurance benefits which can vary widely among insurance plans. If you have not met your deductible, it may be collected at the time of service. If you wish to self-pay for services, please discuss this option with a Head Pain Institute representative.

If the Head Pain InstituteⓇ is out-of-network with your Insurance Company, you will be responsible to bring us all correspondence from the Insurance Company and sign over any insurance checks sent directly to you or make payment directly to the Head Pain Institute.
Non-Insurance Patients
All payments are to be made at the time of service. The Head Pain Institute accepts cash, check, and credit cards. We also offer the option of financing your treatment. If you wish to bill an insurance company any time during or after treatment for reimbursement, we can provide you with the necessary forms upon request. If you have Medicare, they will not allow you to submit a claim for reimbursement.
All Patients
Appointment times are valuable, and many patients have to wait several weeks to get in. That is why it is important for you to make sure you are at your scheduled appointment. A minimum $75.00 fee will be charged for missed appointments without 48-hour advance notice.

A $35.00 fee will be charged for any checks returned for insufficient funds. Any amounts that are 90-days past due may go to collections and you agree to be responsible for legal fees (court, attorney, process server, etc.), collection agency fees, interest charges (2% per month) and any other expenses incurred in the collection of your debt.

If an appliance is not accepted and received by the patient for any reason, the patient will be responsible for paying a $500.00 fabrication fee for each appliance.

If treatment is rendered on a minor child, the parent or guardian who accompanies the child to the appointment is financially responsible for the amount due.

I understand that all fees paid are for services-rendered-fees are not refundable and are not based on the result of treatment. By signing below, you understand and agree to the terms of this Financial Policy:
Patient Signature Acknowledgement*
First Last
Date*
MM slash DD slash YYYY

Notice of Privacy Practices / HIPAA Acknowledgment
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a Privacy Rule to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations

As our patients, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy When it is appropriate or necessary, we provide the minimum necessary information only to those we feel are in need of your health care information regarding treatment, payment or health care operations, in order to provide health care that is in your best interest

We fully support your access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with the physician and not patients) and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent

You may refuse to consent to the use or disclosure of your personal health information, but this must be done in writing Under this Law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information. If you choose to give consent in this document, at some future time you may request to refuse all or part of your Personal Health Information. You may not revoke actions that have already been taken which relied on this or a previously signed consent

Be sure to review the Notice of Privacy Practices for important information about your rights under HAA

By signing below, you acknowledge that the Notice of privacy practice was made available for your review if you request it. You had the opportunity to request a copy for yourself and may view the document on our website.
Patient Signature Acknowledgement*
First Last
Date*
MM slash DD slash YYYY

Insurance benefits
The Head Pain Institute will contact your insurance company to confirm coverage before treatment. Head Pain Institute will provide you pricing based upon the information we receive from your insurance company.

Rarely, but at times, we receive information from insurance representatives that is not accurate. Unfortunately, the issue usually becomes evident only after the claim has been processed through the insurance company.

While the Head Pain Institute will make every effort to obtain accurate information from insurance carriers, we cannot be responsible for inaccurate information we receive.

We encourage you to understand your insurance benefits. A knowledgeable patient is the best defense to ensure charges are accurate. The explanation of benefits (EOB) issued by insurance carriers after a visit is a good reference to understand coverage and charges.

At the Head Pain Institute, we remain available to explain our treatment, charges, and, to the best of our ability, your insurance coverage. At times, you may need to contact your insurance company for further explanation or appeal a decision.

I understand the pricing provided by the Head Pain Institute is based upon information provided by my insurance carrier. I will not hold the Head Pain Institute responsible for any errors by the insurance company when quoting coverage.
Patient Signature Acknowledgement*
First Last
Date*
MM slash DD slash YYYY
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Name
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New Patient Form

Step 1 of 8

What are your three chief complaints for which you are seeking treatment?

Medical History

Allergic Reactions

Current Medications

Health and Medical History

Surgical History

Medical History

Current Symptoms

Head Pain

Jaw Pain

Eye Related Conditions

Ear Related Conditions

Mouth & Nose Related Conditions

Sleeping Conditions

Family & Social History

Epworth Sleepiness Scale

Health Care Practitioners and Patient Communication

Family/Primary Care Physician

Family Dentist

Specialty Providers

Patient Signature Acknowledgement

Consent Form for Care

Financial Policy

Non-Insurance Patients

All Patients

Notice of Privacy Practices / HIPAA Acknowledgment

Insurance benefits

Treatment and/or Medication	Doctor/Provider Name	Approximate Date of Treatment

Medication	Dosage	Reason