New Patient Appointment

Fields marked with a red * are required. Upon full or partial completion of this form, a representative from our New Patient Department will contact you within two business days. If you prefer, please feel free to contact our New Patient Department direct for assistance at 1-800-HEADACH.

Patient Title:

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Patient Address line 1: *

Patient Address line 2:

Patient City: *

Patient State:

Patient Zip Code: *

Patient Country: *

Patient Home Phone number: *

Patient Cell Phone number:

Patient's Email Address:

Patient's Employer Name:

Patient's Occupation:

Patient's Current Employment Status:

Patient's Work phone number:

I prefer to be contacted by:

Spouse's name:

Birth Date:

Gender: *

Preferred Language:

Patient same as responsible party:

Responsible Party First name:

Responsible Party Middle Initial:

Responsible Party Last Name:

Relationship to patient:

Responsible Party's birth date :

Responsible Party's Gender:

Responsible Party's address if different than above:

Responsible Party's phone numbers if different than above:

Responsible Party's Employer Name:

Responsible Party's Occupation:

Responsible Party's Current Employment Status:

Name of primary insurance (enter NA for self-pay): *

Primary insurance state:

Name of Insured (first name):

Name of Insured (last name):

Policy holder's first name:

Policy holder's last name:

Relationship to patient:

Insurance ID number:

Insurance Group #:

Effective date:

Are there any pre-existing conditions?:

If yes, please describe.:

If yes, when does pre-existing condition expire?:

Name of secondary insurance:

Name of Insured (first name):

Name of Insured (last name):

Policy holder's first name:

Policy holder's last name:

Relationship to patient:

Insurance id number:

Insurance group #:

Effective date:

Emergency contact name (person NOT living with you): *

Relationship to patient: *

Home phone number: *

Cell phone number:

Work phone number:

Referring physician name:

Referring physician specialty:

Referring physician address line 1:

Referring physician address line 2:

Referring physician city:

Referring physician state:

Referring physician zip code:

Referring physician country:

Referring physician phone number:

How long have you had headaches?: *

In the last year, have you ever been hospitalized for headaches?: *

In the last six months, have you gone to the emergency room for headache treatment?: *

Are you taking five or more medications for your headache?: *

For over six months, have you been taking medications daily to abort your headaches?: *

Have you seen more than two physicians for your headaches?: *

Do you have headaches more than 15 days each month?: *

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Diamond Headache Clinic

New Patient Appointment

Preferred Pharmacy