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Reason for visit:

Motor Vehicle Accident/work injury

Private insurance ex: Moda, BCBS, Regence

Post surgery

Acute pain

Chronic pain

Congenital

Date Requested Date

Time Requested Time

Emergency contact Emergency contact

Primary Care providers Contact info. referring Doctor,clinic, phone,

Permission:

Do we have permission to contact these physicians if medically necessary?

Do we have permission to send treatment related reports to these physicians?

Insurancce Claim Number: Insurancce Claim Number

Insurance information: company name, plan name/policy/group, phone, adjusters name,billing address or office address.

Attorney (in case of litigation): attorney name, firm, phone, email, address

Date of Injury: Date of Injury:

Home Address: Enter Address

City: Enter City

State: Enter State

Zip code: Enter Zip

Country: Enter Country

Date of Birth: Date of Birth:

Date of injury: Date of injury:

Do you suffer from any allergies? List all allergies...

Are you wearing any medical devices? Are you wearing any medical devices? If yes, what type?

Do you suffer from any skin disorders? List skin disorders here...

Are you currently taking any medications? List medications here....

Have you ever been diagnosed with any conditions: list of conditions...

Have you ever had surgery? If yes explain...

Do you have any concerns about your injury or this type of treatment? explain concerns...

To the best of your ability, please describe your most relevant and serious symptoms: Describe symptoms...

I consent that all information contained on this form is true and correct to the best of my knowledge. I promise to keep my health care providers updated as to any changes in my health and residence.

Continue form here if its a medical claim

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Call today: 503-750-2804 * 1842 NW 25th ave Suite C3 Portland OR 97210 * mail@tactuswellness.com

Call today: 503-750-2804