New Patient Form

Please type in the answers. Please be thorough.

When finished, click the SEND button at the bottom of this page.

 

Your Name:

Address:

Telephone:

email:

Date of Birth:

Healthcare Insurance:

Emergency contact, their relationship to you, and their phone numbers:

Please tell us about your reason for consulting us, and some details about this pain problem:

Please tell us about all aspects of your current health and your medical history. Please be thorough:

Medications:

Allergies to Medications:

Supplements:

Acceptance of office policies/informed consent (please actually read this)

  • I understand that New Mexico Pain Management (NMPM) attempts to be as close as possible to 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 all medical procedures carry some degree of risk. For the many therapies at NMPM, some of the risks include temporary worsening of symptoms, bruising, infection, reaction to local anesthetic or any medicine, and sensations of sharpness, tingling, or other 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 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.

 

I agree to the above. (The form will not send if the box isn't checked.)

If the patient is a minor, type in your name and your relationship to the patient as your signature for the minor (This field is not required):

Note that you have just agreed to not wear fragrances to our office. Remember that on the day of your visit don’t use body care products with fragrances, and avoid using clothes with residues of fragrances, including laundry product fragrances. Our few patients with serious chemical sensitivities thank you.

When done, click this button

NOTE: If you have a very slow internet connection, or if you have Internet Explorer or an older version of another browser (internet program), then there is a very small chance your information may not submit properly. In that case, fill out this page, print this page, and bring the printed paper copy to your initial evaluation, just in case.