Valley Health & Hyperbarics Patient Intake Form Name First Last Date Of Birth Month Day Year Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Emergency Contact First Last RelationshipPhoneSection BreakFor Pediatric Patients OnlyMothers Name First Last Date of Birth Month Day Year PhoneFathers Name First Last Date Of Birth Month Day Year PhoneSection BreakDiagnosis/SymptomsDrug Allergies? yes/no Please listReaction? Hives/Rash/Anaphylaxis other:Food Allergies? yes/no Please listDo you smoke? Yes/No FrequencyPlan on quitting? Yes/NoDo you drink alcohol? Yes/No FrequencyAre you pregnant or breastfeeding? Yes/NoPlease list any surgeriesInterested in:HyperbaricsIV TherapyOzone TherapyOtherPlease List All Medications/Supplements Taken by the Patient. Include Frequency and Dose PleaseSection BreakConsent For TreatmentI,Name First Last authorize the above-named doctor to provide medical care to myself/my minor childName First Last to perform diagnostic testing and I hereby give consent to receive the agreed upon treatment. I have been informed of the reasons for the treatment/procedure(s), along with the expected benefits, risks, possible alternative methods of treatment, and possible consequences involved. I understand that Dr. Feingold does not accept insurance and I have come to Dr. Feingold’s on my own, in search of treatment.Patient Name First Last Date of Birth Month Day Year Parent or Guardian Name First Last Date of Birth Month Day Year Signature of Patient/GuardianDate MM slash DD slash YYYY Section BreakHIPPADr. Benincasa-Feingold MD abides by HIPAA policies. We will not share or disclose your information unless you authorize us to do so. To give Dr. Feingold’s office consent to share your private health information to a family member/friend, please fill out the information below.I,Name First Last give Dr. Feingold permission to release and share medical records with:Person/Entity Name First Last Relationship to PatientSignature of Patient/GuardianDate MM slash DD slash YYYY I authorize the release of ALL of my medical Information Yes No Please Exclude the following documents:I give Dr. Benincasa-Feingold MD, and staff, permission to:Leave a message on my voicemail Yes No Communicate with me via email Yes No Communicate with other Doctors/medical professionals regarding my treatment Yes No
