Name *

First

Last

Email *

Phone *

Date of Birth (MM/DD/YYYY) *

Age *

Gender *

Male
Female
Other

Address *

City, State and Zip code *

Parent/Guardian (For Minors only)

Relationship to minor

Insurance name # 1

Policy holder name

Relationship to policy holder

Self
Spouse
Child

Policy ID number

Group number (if any)

Insurance name # 2

Policy holder name

Relationship to policy holder

Self
Spouse
Child

Policy ID number

Group number (if any)

Medical History

Reason for visit *

Allergies (Medication or Food)

Are you currently experiencing any of the following? Check all that applies.

Explain

Medical History

Explain here

Family History of below conditions in biological parents or siblings?

Explain here

Smoke (Tobacco)

Yes
No

If Yes to above questions, how many packs per day.

Drink Alcohol

Yes
No

If yes to above question, how many drinks per week.

Illegal drugs

Yes
No

If yes to above question, what do you use?

Marital Status

Married
Single
Divorced

Do you have Childrens?

Yes
No

Occupation

Medications (List names, dosage and how many times a day you take).

Name & address of your pharmacy

Surgical History (Date and type of surgeries)

Primary care physician (PCP) name and phone number (if no PCP, then type None).

Do you consent to allow us to send your medical records/notes/lab results etc. electronically via email to you? *

Yes, I consent to receive my medical records via email, which is NOT HIPAA compliant.
No, I do not consent. I prefer secured way of communication such as regular mail, in-person pick-up or fax (additional processing fees will apply).

How did you hear about our clinic? *

If you have already discussed an appointment date and time with us then please write that date/time here.

It is the patient's responsibility to inform our office if you need to cancel or reschedule an appointment at least 24 hours in advance. Cancellation within 24 hours of your appointment or "No Show" will result in a $25 charge or $50 if it's a procedure appointment. *

I agree to above cancellation policy.

Notice of Privacy Practice *

I acknowledge that I received the notice of privacy practice.

Consent to use telemedicine visits, if needed. *

I agree to consent to use telemedicine visits in future, if needed.

Face covering/masks are mandatory in our clinic to reduce exposure due to COVID-19. Please put on your mask/face covering prior to entering in to the clinic. *

I will have my own mask on during inperson appointment.

COVID-19 questionnaire

Do you have fever or have you felt hot or feverish recently in last 3 weeks?

Yes
No

Are you having shortness of breath or other difficulties breathing?

Yes
No

Do you have a cough?

Yes
No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes
No

Have you experienced recent loss of taste or smell?

Yes
No

Are you in contact with any confirmed COVID-19 positive patients?

Yes
No

Is your age over 60?

Yes
No

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes
No

Please type in your first and last name below. This serves as an official signature for the New patient registration form. This electronic form may be executed using an "electronic signature," as the term is defined in California's Uniform Electronic Transactions Act (Cal. Civ. Code § 1633.1, et seq.) An electronic signature will have full legal effect and enforceability and shall be deemed to have been duly and validly delivered electronically. *

Our clinic also offers Concierge membership, which gives you a 24/7 access to our Neurologist directly via text/calls, FREE unlimited follow ups, priority, after-hours and weekend appointments as needed, quality unrushed personalized care, discount on procedures i.e. EEG, EMG, Holter monitor, etc. There is no long-term commitment so it can be cancelled anytime. All for only $75/month ($50/month if we are in-network for your insurance). Would you be interested in this Concierge membership? *

Yes
No
Not right now. I will think about it.

We have implemented a policy that enables you to maintain your credit card information securely on file with We-Care Neurology Inc. For patient who has medical insurance that we are in-network for, the co-pays are due at the time of service/appointment. If you have an unmet deductible, you may see an additional charge on your credit/debit card few days after your appointment once we receive an exact amount to apply toward deductible from your insurance, if applicable. For self-pay (uninsured or out of network insurance, full visit fee is due at the time of service. Our visit fees for services are listed at www.wecareneuro.com/pricing. This step is required to fully confirm your appointment. By providing us with your credit card information, you are giving We-Care Neurology Inc permission to automatically charge your credit card on file for your co-pay, deductible, etc. at the time of service. By signing this you authorize this agreement will remain in effect until the expiration of the credit card account and that you may revoke this form at any time by submitting a written request. Unless you want to change payment methods, any balance owed will be charged to your credit card promptly. This in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment. Multiple Users: This card will only be authorized for the use of the credit card holder, his/her minor(s), or any person(s) listed below. You can always call us for any billing questions/concerns or need more explanation of any charges. We accept Cash, Credit/Debit Cards and HSA Cards. It is the patient’s responsibility to inform our office if you need to cancel or reschedule an appointment at least 24 hours in advance. Patients are responsible to pay for any test/injections or procedures that insurance does not cover. It is the patient's responsibility to verify with their insurance about what service and treatment plans are covered by their insurance. If we submit claims and insurance rejects or denies the claim, the patient will be responsible for the payment. All payments and balances due must be paid within 30 days of receiving a statement in the mail. No new appointment can be created until this balance is paid in full. If payment is not paid within 3 billing cycles, then the patient will be discharged from the practice. Once a patient has been discharged from this practice, he cannot be treated by this office any longer. This includes but is not limited to medication refills and filling out any paperwork. If we turn the pending balance on the account to the collection agency, the fees associated with the collection agency will be the responsibility of the patient. *

I agree to have my payment information on file.