Welcome to new patient and client registration! Please download and complete the intake forms and bring them with you to your first appointment.
IMPORTANT INFORMATION TO READ ABOUT REGISTRATION:
- The first three forms should be completed prior to your first visit.
- If you answer “yes” to questions 1-7 on the medical questionnaire on the Patient Intake Form, you may need a doctor’s referral for therapies. Please consult Dr. G’s office to determine if a referral is needed.
- If you are concerned about health problems and/or your ability to participate in group yoga or Pilates, physical therapy or sports medicine therapies, please contact the office at the form below.
- Dr. G does is not a participating Medicare provider. If you would like to be seen for wellness or maintenance programming ONLY and you are on Medicare, then Dr. G can discuss the parameters for being seen.
Patient Privacy Disclosure Statement:In filling out the patient registration, I understand that EudeMOMia will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.
New Patient & Client Registration
These forms should be completed PRIOR to your first appointment. If you have any of the other issues listed below, please also complete the forms that are related to the issue.
- Telehealth Consent (MUST BE COMPLETED FOR ALL telehealth & phone consults)
- Dry Needling – If you believe that dry needling may be right for you, please complete this consent form.
- For those with longstanding or persistent pain, please complete this online quiz and bring a copy of the results to your first appointment. Trouble with the online version? Print it out and take it: SF-36 Intake Form.
Medical Record Release Form
If you need to share your medical records from Dr. G’s office with another provider, this form must be completed.
Please complete these forms if you have any hip, pelvic, or back pain or pain related to sex or are postpartum (no matter how many years it has been since your last birth). If you are a dancer or gymnast, please also complete these forms.
- Women’s Health Patient History Intake Form
- Bladder Diary Instructions
- Bladder Diary
- Dancer and Women’s Health Inventory
- Edinburgh Postpartum Depression Inventory
Neck and/or Back Pain
Please complete if you have neck or back pain.
For Ayurvedic Consults Only
If any of these forms are needed Dr. G will have you complete them at a later date.