New Patient Information

Please bring the following items with you to your appointment: • Valid Photo ID • Insurance Cards • The enclosed forms filled out. • Previous medical records and MRI reports associated with your pain condition. On your initial consultation we will perform a complete evaluation and assess your current medical condition. Thank you for choosing The Brooks Accident & Injury Clinic.

Male Female

Emergency Contact

Employed Unemployed Unemployed due to accident
Single Married Widowed Divorced
Clerical/Office Light Labor Moderate Labor Heavy Labor

General Information About Your Injury

Motor Vehicle Personal Injury Worker's Comp
Yes No
Yes No
Yes No
Yes No
Driver Passenger
Yes No
Same Day Next Day Days Later

General Health Information

Yes No
Latex Tape Iodine Other
Yes No
Aspirin Anti-Inflammatory Lovenox Coumidan Warfarin Platal Aggrenox Pradaxa Ticlid Plavix Heparin
Never Occasionally Daily
Gallbladder Appendix Hernia Laparotomy Other
Hysterectomy Tubal Ligation C-Section Other
CABG Valve Repair Stent Placement Aneurysm Vascular Other
Fusion Laminectomy Discetomy Other
HIp Knee Foot Elbow Shoulder Other
Yes NO

Family Medical History

Please check any medical conditions and indicate the family member associated: Self / Mother / Father

Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Yes No
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Self Mother Father
Yes No

About Your Injury

Spasms / Cramping Numbness / Tingling Dull / Achy Sharp / Stabbing Shooting Constant Pain Intermittent Pain Radiating
Spasms / Cramping Numbness / Tingling Dull / Achy Sharp / Stabbing Shooting Constant Pain Intermittent Pain Radiating
Spasms / Cramping Numbness / Tingling Dull / Achy Sharp / Stabbing Shooting Constant Pain Intermittent Pain Radiating
Spasms / Cramping Numbness / Tingling Dull / Achy Sharp / Stabbing Shooting Constant Pain Intermittent Pain Radiating

Personal Medical History (Ongoing Medical Problems)

Chills Fatigue Fever Night Sweats Other
Blurred Vision Photophobia (Light Sensitive) Visual Changes Other
Hearing Changes Bleeding Gums Dental Problems Other
Chest Pain Palpitations Fast Heart Rate Slow Heart Rate Edema (swelling) Other
Numbness / Tingling Seizures Memory Impairment Weakness Incontinence Loss of Balance Loss of Coordination Other
Depression Anxiety Suicidal Thoughts Sleep Difficulty Restlessness Crying Agitation Insomia Ohter
Cough Wheezing Shortness of Breath Other
Taking Blood Thinners Easy Bruising Excessive Bleeding Swollen Glands Other
Neck Pain Low Back Pain Muscle Weakness Morning Stiffness Joint Pain Joint Stiffness Difficulty Walking Other
Rash Hives Other
Hair Loss Excessive Thirst Other
Diarrhea Constipation Nausea / Vomiting Abdominal Pain Jaundice Reflux Other

Consent For Treatment

I certify that the above information is accurate, complete and true. I authorize The Brooks Clinic Providers, Physicians, associates, assistants, and other health care providers it may deem necessary to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. I give consent for The Brooks Clinic Providers and physicians to retrieve and review my medication history. I understand that this will become part of my medical record. I acknowledge that I have had the opportunity to review The Brooks Clinic notice of privacy practices, which is displayed for public inspection at its facility. This notice describes how my protected health information may be used and disclosed, and how I may access my health records. I authorize The Brooks Clinic to release my protected health information (medical records) in accordance with its notice of privacy practices. This includes, but not limited to my referring physician, primary care physician, and any physician(s) you may be referred to. I also authorize The Brooks Clinic to release any information required in obtaining procedure authorization or the processing of any insurance claims. I understand that The Brooks Clinic will not release my protected health information to any other party (including family) without completing a written patient authorization for use and disclosure of protected health information form available at the facility or in the new patient packet.

RELEASE OF INFORMATION If a patient wishes another individual to receive medical information such as test results, etc., or if the patient is unable to receive those results, that patient may choose to designate a person who is authorized to receive that information. I hereby authorize the release of my medical information to the following designed persons: (Check one or all)

My signature indicates that I have read the above and grant the request. I understand that if I do not sign, or list any person, the information will not be given to anyone but the patient. I also understand that I can revoke this authorization at any time. The request must be in writing to The Brooks Accident & Injury Clinic.

Yes No

I acknowledge that this electronic signature represents my true signature and will be used throughout this patient information form. Anywhere I type my name, I intend this to be my legally binding signature.

By typing my name, I acknowledge this as a true representation of my signature.

Assignment of Benefits

Release of information, assignment of benefits and out-of-network contract: I authorize, The Brooks Accident & Injury Clinic, and its employed physicians to release any necessary information regarding any illness/injury to my insurance company and/or attorney in regards to the above accident. I authorize the responsible insurance company and/or attorney to pay directly to The Brooks Accident & Injury Clinic all medical benefits pertaining to services rendered by this clinic, if any, otherwise payable to me. If the responsible insurance policy prohibits direct payment to my physician, then I hereby instruct and direct my insurance carrier to make out any benefit check payable to me and mail as follows THE BROOKS ACCIDENT AND INJURY CLINIC 820 Northwest 13th Oklahoma City, OK 73106 I understand that charges which are not payable by the insurance are my responsibility. I understand that my credit report may be obtained to assist The Brooks Accident & Injury Clinic in any collection efforts. I understand that if I have health insurance in force during my treatment for this accident, I am contracting outside of my network for any treatment received relating to this accident. Any network discounts or write-off’s will not apply for any treatment related to this accident. I understand that The Brooks Accident & Injury Clinic will not file to my health insurance for services rendered relating to this accident, UNLESS it becomes the only source of payment; at which time it will be out of network and I am still ultimately responsible for any balance not paid by any other source.

By typing my name, I acknowledge this is a true representation of my signature.

Assignment, Authorization and Lien

I, hereby authorize and direct my insurance company and /or my attorney, to pay directly to The Brooks Accident & Injury Clinic such sums as may be due and owing this office an assignee for services rendered the undersigned, by reason, of accident or illness, and by reasons of any other bills that are due or may become due, and to withhold such sums from any disability benefits, including, but not limited to foundation grants, governmental or agency benefits, medical payments benefits. No fault benefits, health and accident benefits, worker’s compensation benefits, or any other insurance benefits obligated to reimburse the undersigned or from any settlement, judgment or verdict on my behalf as may be necessary to adequately provide for any financial obligation owed to this office and assignee. The parties further agree that, in the event my insurance company obligated to make payments to me upon charges made by this office and assignee for its services refuses to make such payments, this agreement is to act as an assignment of the undersigned rights and benefits to the extent of the office’s services provided; therefore, I hereby assign and transfer to this office and assignee any and all causes of action that I might have or that might exist in my favor against such company and authorize this office and assignee to prosecute said cause of action either in my name or in the assignee’s name and further I authorize this office and assignee to compromise, settle, or otherwise resolve said claim or cause of action as they see fit. I hereby further give a lien to said office against any and all insurance benefits named herein, and any and all proceeds of any settlement, judgment or verdict which may be paid to the undersigned as a result of the injuries or illness for which I have been treated by said office and assignee. The undersigned patient and assignee further agree that the assignee’s right for payment from the undersigned patient shall be tolled by any statute of limitation until a reasonable time has lapsed after either negotiations or litigation between third parties and the undersigned patient are resolved. It is further agreed that the undersigned patient shall remain personally responsible for the total amounts due to this office and assignee for its services. This office an assignee for and in consideration of their rights for immediate payment on the indebtedness owed at this time and which may become due in the future agrees to forego collections of the aforementioned monies owed for a reasonable length of time. This assignee, however, reserves the right to revoke this agreement upon thirty (30) days written notice to the undersigned patient this assignee demands payment after said notice has expired. I authorize this office to release any information pertinent to my case to any insurance company, adjustor, or attorney to facilitate collection under this assignment, lien, and authorization. I agree that the above mentioned office by given power of attorney to endorse and/or sing my name on any and all checks for payment of any indebtedness owed this office and assignee. I do attest that I have come to this clinic for purposes of acquiring medical care. I am here for my medical problems and have no intent to mislead or defraud my treating practitioners in any way that might result in inappropriate charges to third party payers, federal, state, or local government, or insurance carriers. Further I attest that my injuries are real and that I am in pain and in need of medical treatment as a result of the medical condition for which I am consulting The Brooks Accident & Injury Clinic. I also attest that I understand the context of this statement with complete comprehension of its content.

Referral To The Brooks Clinic

TV: KFOR 4 TV: KOCO 5 TV: KWTV 9 TV: Fox 25 TV: The CW TV: KAUT 43 TV: Cable or Satellite Other Internet Search Facebook Friend / Relative Billboard I am a Former Patient Phonebook Sign on Building (drive by) Radio: Perry Broadcasting Radio: KYSS Other Doctor / Hospital / ER Attorney

If referred by an attorney, please give name

If referred by a doctor or medical facility, please give name

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