New Patient Information Form - New Mexico Pain Management

Name of physician or other healthcare provider who referred you:

Address:

Phone:

Email:

Primary healthcare insurance:

Secondary healthcare insurance:

If applicable, give exact date of injury (accident) or date of illness (first symptom):

If you’ve had the same or similar illness give first date:

If possible, we encourage you to type here a detailed medical history, including details of your current main complaints, other aches and pains, illnesses, other injuries, surgeries, hospitalizations, family medical history including siblings, children and grandchildren. Also include sleep, digestion, typical meals, level of stress, and exercise.

Informed Consent/Acceptance of NMPM Office Policies (please read carefully)
I understand that all medical procedures carry some degree of risk. For the many therapies at New Mexico Pain Management (NMPM), some of the theoretical risks include temporary worsening of symptoms, occasional bruising, the extremely rare possibility of infection, reaction to local anesthetic or any medicine, and sensations of sharpness, tingling, or other passing discomforts. These risks are very small, especially compared to the risks in surgery.

I understand that my physicians at NMPM will explain further, while also discussing the likely number, frequency, and outcomes of treatment. I retain my right to choose, accept or reject any diagnostic procedure or treatment, or any part of it, before or during diagnosis or treatment. I understand that NMPM is a “fragrance-free office.” I appreciate that some patients receiving care at NMPM are highly sensitive to and may become ill from perfumes, colognes, scented body care products, scented laundry products, or residual scents in clothes previously stored with moth balls. I agree to avoid using all such scented products and to avoid wearing clothes that carry residues of such scents on days I am to be in this office.

I understand that NMPM makes extra efforts to maintain a clean and minimally dusty office environment, with special HEPA filtration in key rooms. I will make a reasonable effort to avoid wearing coats or other outerwear that is particularly dusty or has with excessive pet hair, and I will leave my coat in the designated coat closet before entering treatment/procedure rooms.

I agree to pay for each medical service at the time it is provided. I understand that if any other special arrangement is made with NMPM regarding delay of payment (for example some auto accident cases) this will in no way take away my full personal responsibility to pay for all of my medical expenses. If necessary for the collection of my health insurance benefits, I hereby assign benefits to NMPM.

I understand that I can request a copy of NMPM’s privacy policy, as required by Federal law. I give my permission to have my medical records transmitted to health insurance and any other third party payors, as needed to process my claims, and to attorneys or other healthcare providers with whom I am working. I also give my permission for NMPM to send me newsletters or other information by mail or email, or for their personnel to call me periodically to maintain up-to-date contact information.

Type your full name if you agree to the above terms:

If the new patient is a minor, and your are their legal representative, type your full name, and your relationship to the minor new patient, if you and the minor patient agree to the above terms:

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