Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

How would you describe your pain (please check all that apply):

Dull

Shooting

Sharp

Constant

Ache

Tingling

Burning

Numb

Discomfort

Other

Option Two

Are you currently working?

Yes

No

Yes, with Restrictions

Have you had any of the following in the past 2 weeks? Is your MD aware?

Please select all that apply:

Yes, MD is aware

NO, MD is not aware

Sleep Disturbance

Dizziness

Nausea

Unexplained Weight Loss or Gain

Weakness

Headaches

Double Vision

Numbness

Swelling

Night Sweats

Tingling

Vomiting

Night Pain

Fatigue

Fever

Slurred Speech

Changes in Bowel or Bladder habits

Do you have a history of any of the following?

High Blood Pressure

Stroke/TIA

Heart Problems

Osteoporosis

Diabetes

Cancer

Pregnancy

None of the above

How would rate your general health?

Excellent

Good

Fair

Poor

HIPPA CONSENT FORM *

Our notice of Privacy Practice provides information about how we may use and disclose protected health information about you. The Notice contains a Patient’s Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting or Privacy Officer @ 310-573-9553. You have the right to request that we restrict how we protect health information about you, is used or disclosed for treatment payment and health care operations. You have the right to revoke this Consent, in a written statement, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Cypress Center provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The Cypress Center has a Notice of Privacy Practice and the patient has the opportunity to review this Notice. The Cypress Center reserves the right to change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information, but The Cypress Center does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures with then cease. The Cypress Center may condition receipt of treatment upon the execution of this consent. Please sign by ELECTRONIC SIGNATURE:

First Name

Last Name

Today's Date *

MM

DD

YYYY