The Jackson Clinics

I have read and understand the above guidelines. *

Which Jackson Clinic will you be visiting? *

Centreville in Centreville, VA Fairfax in Fairfax, VA Franconia in Alexandria, VA Herndon/Elden St. in Herndon, VA Herndon/Worldgate in Herndon, VA Lorton in Lorton, VA Manassas in Manassas, VA Oakton in Oakton, VA Old Town in Alexandria, VA Shirlington in Arlington, VA Skyline in Falls Church, VA Tysons in Mclean, VA   Find the location nearest you

Patient Information

Title Mr. Mrs. Miss Ms.

First Name *

Middle Name

Last Name *

Is this your legal name?

Yes

No, my legal name is

Marital Status Single Married Separated Divorced Widowed

Sex Female Male

Date of Birth *

Age

Contact Information

Street Address *

City *

State *

Postal Code *

Home Phone Number * e.g., (123) 456-7890

E-mail *

Who is your primary care physician?

Date of onset/problem

Occupation

Employer

Employer Phone Number e.g., (123) 456-7890

Why did you choose The Jackson Clinics?

Insurance Plan Hospital Family Friends Close to home/work Yellow pages Web Search (Google, Bing, Yahoo, etc.)

Doctor:

Other reference:

Names of other family members seen here?

Insurance Information

Is this patient covered by insurance? * Yes No

Name of Primary Insurance

Subscriber's Name

Date of Birth

Group Number

Policy Number

Co-Payment e.g., $12.34

Patient's Relationship to Subscriber

Self Spouse Child

Other relationship:

Secondary Insurance

Name of Secondary Insurance (if applicable)

Subscriber's Name

Group Number

Policy Number

Person Responsible for Bill

Name of Personal Responsible for Bill

Is this person a patient here? Yes No

Date of Birth

Address (if different)

City

State

Postal Code

Home Phone Number e.g., (123) 456-7890

Occupation

Employer

Employer Street Address

City

State

Postal Code

Employer Phone Number e.g., (123) 456-7890

Lawyer

In Case of Emergency

Name of Local Friend or Relative List someone not living at the same address

Relationship to Patient

Home Phone Number e.g., (123) 456-7890

Work Phone Number e.g., (123) 456-7890

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to The Jackson Clinics, LLC. I understand that I am financially responsible for any balance. I also authorize The Jackson Clinics, LLC or insurance company to release any information required to process my claims. *

I have had the following conditions

High Blood Pressure

Heart Trouble

Circulation Problems

Seizures

Dizzy Spells

Diabetes

Other Illness

Breathing Problems

Fracture

Stroke

Arthritis

Acrophobia

Claustrophobia

Have you ever had surgery? *

No

Yes, I had the following operation(s): Include Date(s), Operation(s), and Outcome(s)

Do you have any metal anywhere in your body (other than your teeth)? * Yes No

Do you have a Cardiac (heart) Pacemaker? * Yes No

(Women Only) Are you now pregnant?

No

Yes, my last period occurred on:

List medical tests done for this condition

List any allergies you have

List any medications you are now taking

Have you ever had Physical Therapy treatments before? *

No

Yes Please indicate Where, When, and for What problem

Describe briefly the history of your present accident or illness

Please list any past or present medical conditions you have

Please list prior accidents or work injuries

Work Status * Regular Duty Light Duty Off Duty

I have received the Notice of Privacy Practices from The Jackson Clinics. *

Discussion of Treatment/Medical Information

Student Involvement

Place of Treatment

Financial Policy Statement