Your Cell Regeneration | New Patient Intake

Legal name

Patient identity

Use patient legal identity for charting and consent.

Legal first name * Legal last name * Suffix Preferred first name

Demographics

Contact and patient details

We use this for scheduling, chart setup, and patient outreach.

Permanent address * Apt / suite City * State * ZIP * Phone * Birth date * Email address *

Gender Language Marital status Race / ethnicity

Emergency contact

Who should clinic contact?

Used if care team needs support person or urgent outreach.

Contact name * Phone * Relationship to patient * Relative not residing with patient Relative phone

Employment and coverage

Billing and insurance context

Coverage details can be completed later if patient does not have them today.

Employer name Employer phone Responsible party name Responsible party relationship Responsible party address Responsible party city Responsible party state Responsible party ZIP

Insurance company Medical ID / member ID Policy holder name Policy holder relationship

Full SSN is intentionally excluded from this online flow.

Baseline

Vitals and medical history

Give care team enough detail to prepare physician review.

Height Weight (lbs)

Past medical history

Current or prior diagnoses

Other significant illnesses

Reason for visit

What has happened and what are main issues?

Reason(s) for seeking medical attention *

Surgical history

List all major surgeries with estimated dates

Allergies

Medication reactions and pharmacy

No known allergies to report

Preferred pharmacy Pharmacy address Pharmacy phone

Medication list

Current medications with dosages

No medications to report

Supplements

Natural supplements with dosages

No supplements to report

Social history

Home life and habits

Spouse / significant other status Spouse age Spouse major illness Number of children Number living Number deceased

Children ages

Caffeinated beverages per day Do you smoke? If past smoker, how long ago? Do you drink alcohol? Number per week Medical marijuana license Recreational drug use If yes, list recreational drugs Exercise regularly Exercise frequency Sleep hours per night Do you get enough sleep? Wake up feeling rested? People in household Who does most housework? Who does most shopping? Who does most yard work?

Current care and symptom pattern

How symptoms move through day

Referred to orthopedic surgeon? Orthopedic surgeon name Currently under orthopedic care? Date of last appointment Does anything ease your pain? If yes, please describe Able to get comfortable at night? Once you start moving, does it get better? What is it like at end of day? At this time do you feel like you are getting

Morning pattern

How do you feel upon rising in the morning?

Stiff Sore Fine Other

Other morning feeling

Legal agreement

Patient treatment and arbitration agreement

Regarding medical care and services provided or to be provided, IT IS AGREED: THE ATTENDING PHYSICIAN will, to the best of his/her skill and knowledge, provide to the patient such medical care and services as possible and practical in the light of circumstance. THE PATIENT will cooperate fully with the ATTENDING PHYSICIAN by obtaining medications as prescribed, by following instructions of the ATTENDING PHYSICIAN, by adhering to such treatment regimen, or course of action as may be set forth, and by paying all fees and charges in full as billed or as provided by prior special programs arrangements. IT IS AGREED: Because of differences in human constitution and response, there is no way possible to warrant the outcome of such medical care and services.

In the event of any controversy between PATIENT or dependent, whether or not minor, or the heirs-at-law of personal representative of a PATIENT, as the case may be, and the ATTENDING PHYSICIAN, including agents and employees, involving a claim in tort or contractual, the same shall be submitted to arbitration within fifteen (15) days after the PATIENT or ATTENDING PHYSICIAN shall give notice to the other of demanding arbitration of such controversy. The parties to the controversy shall each appoint an arbitrator and give notice of such appointment to the other. Within a reasonable amount of time after such notices have been given, the two arbitrators, so selected, shall select a neutral arbitrator and give notice of selection thereof to the parties. The arbitrators shall hold a hearing within a reasonable time from the date of notice of selection of neutral arbitrator. All notices or other papers required to be served shall be served by the United States mail. Except as provided herein, the arbitration shall be conducted in accordance with and governed by the provision of Title 9 of the California Code Civil Procedure. The PATIENT may withdraw from the arbitration portion of his/her agreement within 90 days from the date of his/her agreement by notification of his/her intent to do so to the ATTENDING PHYSICIAN by registered mail.

By our signatures, we consent to this agreement, and each acknowledges receipt of a true copy thereof.

I consent to patient treatment and arbitration agreement. *

General treatment consent

Consent for medical treatment

I consent to evaluation and treatment as described above. *

Patient signature

Typed signature and attestation

Patient signature * Signature date * Patient name (printed) * Printed date *

Physician signature remains clinic-use only after review.

Concierge intake, rebuilt for calmer completion.

Patient information