Patient Registration Forms

Securely complete your patient registration forms for Best Life Primary Care.

Status *

New Patient

Returning Patient - If so, you can exit the page as we have your information.

Full Name *

Enter Date of Birth Below *

Sex *

Male

Female

Social Security # *

Address *

City *

State *

Zip Code *

Phone *

Please select the option that applies to your primary phone number. *

Cell

Home

Work

Secondary Phone Number

Preferred Contact Method *

Phone

Text

Email *

To be used for provider communication, follow up, patient portal, and practice related material. We DO NOT share email information with other parties. You may choose to remove any time

Employer *

Job Title *

Preferred Language *

English

Spanish

Other

Please enter other language if applicable.

Preferred Pharmacy *

Insurance Information

Policy Holder's Date of Birth *

Primary Insurance Company *

Name of Policy Holder *

Same as above

Other

Please enter the name of the policy holder if "other" was selected above.

Policy Holder's Relationship to Patient *

Self

Mother

Father

Other

If "Other" was selected above please enter the relationship to the policy holder below

Policy Holder's Social Security # (Only required if different than above)

Subscriber Number *

Group Number *

Upload a copy of your insurance card [FRONT]

Upload a copy of your insurance card [BACK]

Please enter the name of your Secondary Insurance Company if applicable

Name of Secondary Policy Holder if applicable

Secondary Group Number if applicable

Secondary Subscriber Number if applicable

In Case of Emergency

I hereby give permission to disclose and discuss any information related to my medical condition(s) with the following listed individual: *

Please enter your relationship with the above listed individual. *

Please enter your emergency contacts phone number. *

Permission to contact: *

Yes

Emergency Contact #2

Please enter your relationship with emergency contact #2

Please enter your emergency contact #2's phone number.

Permission to contact emergency contact #2 *

Yes

Reason for Today's Visit

Please Describe Symptoms *

Onset/Injury Date

Please list other treatment received if not shown above

Please list current medications prescribed by another provider or anything you are taking over the counter. Enter "n/a" if not applicable. *

Please enter the dosage of the medications listed above. Enter "n/a" if not applicable. *

Condition(s) that requires the medications listed above. Enter "n/a" if not applicable. *

Medical History

If you selected cancer or other, please elaborate on the condition:

Please list medication allergies and the allergic reaction that occurs below. Enter "N/A" if not applicable. *

Please list supplement allergies and the allergic reaction that occurs below. Enter "N/A" if not applicable. *

Please list food allergies below and the allergic reaction that occurs. Enter "N/A" if not applicable *

Please list other allergies below. Enter "N/A" if not applicable. *

Please list any other surgical history. Enter "N/A" if not applicable *

Any hospitalizations besides surgery? *

Yes

Family History

Mother *

Alive

Deceased

Adopted/Unknown Family History

Father *

Alive

Deceased

Adopted/Unknown Family History

ADD/ADHD *

Mother

Father

Other

None

Please enter the relationship to affected family member if "other" was selected above.

Alcoholism/Substance Abuse *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected above.

Alzheimer's/Dementia *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected.

Arthritis *

Mother

Father

Other

None

Please list the relationship to your family member if other was selected above.

Asthma *

Mother

Father

Other

None

Please list the relationship to affected family member if other was selected above.

Auto Immune Disease (ex: Lupus) *

Mother

Father

Other

None

Please provide the relationship to your family member if other was selected above.

Cancer (please elaborate below if selected) *

Mother

Father

Other

None

Please provide the relationship to the family member if other was selected above.

COPD *

Mother

Father

Other

None

Please input the relationship to the affected family member if other was selected above.

Diabetes *

Mother

Father

Other

None

Please input your relationship to the affected family member if other was selected.

Eczema/Psoriasis *

Mother

Father

Other

None

Please enter your relationship to the affected family member if other was selected.

Heart Disease *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected.

Hemodialysis *

Mother

Father

Other

None

Please enter the relationship to the affected family member if other was selected.

Hepatitis *

Mother

Father

Other

None

Please enter the relationship to your affected family member if other was selected.

High Blood Pressure *

Mother

Father

Other

None

Please enter the relationship to your affected family member if other was selected above.

High Cholesterol *

Mother

Father

Other

None

Please list your relationship to the family member if other was selected above.

Kidney Disease *

Mother

Father

Other

None

Please list the relationship to the affected family member if other was selected above.

Obesity *

Mother

Father

Other

None

Please list the relationship to the family member if other was selected above.

Psychiatric Disorder *

Mother

Father

Other

None

Please list the relationship to your affected family member if other was selected above.

Seizure Disorder *

Mother

Father

Other

None

Please list the relationship to your family member if other was selected.

Stomach or GI Problems *

Mother

Father

Other

None

Please list your relationship to the affected family member if other was selected above.

Stroke/ITA *

Mother

Father

Other

None

Please list the relationship to your affected family member if other was selected.

Thyroid Problems *

Mother

Father

Other

None

Please list the relationship to the affected family member if other was selected.

Social History

Amount/Day *

Number of years: *

How many alcoholic beverages do you consume per week? *

How many caffeinated drinks do you consume per day?

Drug Use: *

No history of recreational drug use

Former use of recreational drugs

Current use of recreational drugs

How do you spend most of your time at work? *

Sitting

Standing

Walking

N/A

How many hours do you work per week? *

Review of Systems

(Check all that apply)

Constitutional *

Weight Loss

Fatigue

Fever

N/A

Respiratory *

Cough Easy

Wheezing

Chills

N/A

Endocrine *

Loss of hair

Heat/Cold Intolerance

N/A

Psychiatric *

Anxiety/Depression

Mood Swings

Difficulty Sleeping

N/A

Hematology/Lymph *

Brusing

Gums Bleed Easily

N/A

Skin *

Rash/Sores

Lesions

Itching/Burning

N/A

IMPORTANT INSURANCE INFORMATION

To patients with Medical Insurance Coverage,

All of our doctors and providers here at Back In Action Medical Center/Best Life Primary Care, have accepted to be a health care provider for certain insurance companies. The insurance you provide us with is a policy you have chosen either as an individual policy or through your employer. Please understand that we DO NOT determine the coverages, stipulations, frequencies, or clauses on your insurance plan. It is your responsibility to understand the coverages, stipulations, frequencies, and clauses in your plan.

Our office staff requests a BASIC “breakdown of benefits” by either Automated service, Fax, or Online.

(It will be electronically generated from your insurance company or clearinghouse)

We then give you an ESTIMATED COPAYMENT/DEDUCTIBLE price based on the information received from your insurance. Please keep in mind that in some cases, if you have a visit(s) in other facilities the maximum or deductibles may change your Out-Of-Pocket expenses. Most of the time we are not aware of other claims that may be processed when we figure out your estimated copay and or deductible. Therefore, you may have to pay more than what was originally calculated as your estimated payment.

Once services are rendered, our billing team will submit the claim to your insurance company with any imaging and or other necessary attachments. Once your insurance company processes the claim, we both will get a breakdown of benefits that will explain in detail what was paid and how it was determined by your insurance carrier.

If there is a balance on your account for the difference that we have collected, you will then receive a bill from our office or be asked to pay it on your next office visit. If there was an overpayment on your account, it will be applied as a credit and will be used for your next date of service.

OUTSIDE LABORATORY AND RADIOLOGISTS

Please understand that BACK IN ACTION MEDICAL CENTER may send lab specimens to an outside laboratory or send X-Rays taken by Back In Action to an outside Radiologist for over reading. I give permission for those outside laboratories and Radiologists to bill my insurance for their services. I understand that I may incur additional charges as a result of those outside laboratory tests or radiologist. I understand that BACK IN ACTION is not responsible for payment to those laboratories and/or radiologist.

(Please keep I mind that our contracted rates may change year to year with different insurance companies, therefore may result on us making certain debit or credit adjustments to your account.)

Please understand it is your responsibility to update our office with any changes. Including, health insurance, address change, and contact information.

Enter Full Name Below *

Please sign and date below stating your acknowledgement of this policy. *

Clear

Please Enter Today's Date *

Ownership Notice to Patients

Because of concerns that there may be a conflict of interest when a physician refers a patient to a health care facility in which the physician has an ownership interest, Florida passed a law (the “Patient Self-Referral Act of 1992,” FL Statute Section 455.654).

Under this law, I must disclose my ownership in this facility and tell you about alternative places where you may go to obtain these services. This disclosure is intended to help you make a fully informed decision about your health care. You have the right to obtain healthcare items or services at a location or from a provider or supplier of your choice, including the facility in which I am owner. I assure you that you will not be treated differently if you do not choose the facility listed below in which I have an ownership interest.

Dr. Robert McLaughlin has an ownership in: Back In Action Medical Center, LLC, Proactive Health and Wellness, dba Back In Action Chiropractic, and Access 365 Urgent Care, PMB Health Solutions LLC/dba Back In Action Chiropractic, and M&R Wellness Center, LLC/ dba Back In Action Chiropractic.

Dr. Michael Purificati has an ownership in PMB Health Solutions LLC/dba Back In Action Chiropractic and M&R Wellness Center LLC/dba Back In Action Chiropractic.

Alternative Medical facilities in which we do not have ownership:

1. Jensen Beach Urgent Care

2. Med Stat Urgent Care

3. Martin County Department of Health

4. Dr. G’s Urgent Care

5. Helix Urgent Care

Alternative Chiropractic facilities in which we do not have ownership:

1. Complete Care Chiropractic

2. Life Chiropractic

3. Vital Wellness Center

4. Keystone Chiropractic

5. Hoffman Chiropractic

Enter Patients Name Below *

Please Sign in the Box Below: Parent, Guardian, or Personal Representative. *

Clear

Input the Date Below *

If Not Patient, Please Enter Name of Legal Guardian and Relationship *

Medical Information Release Form

(HIPPA Release Form)

This Release of Information will remain in effect until terminated by me in writing.

First and Last Name *

Enter Date of Birth *

Release of Information

I authorize the release of information including the diagnosis, records, examination rendered to me, and claims information. This information may be released to: *

Please enter the relationship to the individual you are authorizing the release of information below. *

Select "Do Not Release" below if information is not to be shared with any one.

Do Not Release

Messages

How should we contact you by phone? *

Home

Cell

Work

If unable to reach you: *

You may leave a detailed message

Please leave a message asking me to return your call

Other

If "Other" was selected above please enter details below.

What times are best to reach you? *

Morning

Early Afternoon

Late Afternoon

Please Sign Your Name Below *

Clear

Enter Date Below *

Informed Consent for Disclosure of Medical Health Information

First Name

Last Name

Please Enter Your Date of Birth Below

I authorize the following health care provider:

Disclosing Parties Name (Health Care Provider)

Disclosing Party's Street Address

Enter Disclosing Parties Phone Number

Fax Number

To Disclosure to the Following Party:

Disclosing Party's Name - Health Care Provider

Enter their Street Address

Enter Phone Number

Fax #

These Records are Needed for an Appointment on What Date?

Patient/Legal Representative Signature

Clear

Please Enter the Date Below

When an appointment is scheduled for you with Michael Carpino or Misty Gaddis at Back in Action/Best Life Primary Care, it is your responsibility to confirm your appointment 24hrs prior to the appointment time. The front desk team will call and or email you to confirm your appointment. In the event you do not answer a voice mail will be left. If you as the patient do not make conformation of your scheduled appointment within 24hrs your appointment will be canceled and rescheduled for a later date. If the appointment is confirmed and you do not show up, you will be billed a $50.00 no show fee. We understand that circumstances will arise that will result in you having to cancel please give us a courtesy call 24hrs prior to your scheduled time to prevent the no show fee being charged.

We value you as one of our patients and hope you understand why this is a necessary office policy.

Please sign and date below stating your acknowledgement of this policy.

Patient Full Name *

If Not Patient, Name of legal guardian:

Signature (Sign Here) *

Clear

Date *

Appointment Notifications *

I agree to receive SMS and email appointment updates from Back In Action Medical Center. Opt-out anytime.