Patient Intake Forms — serving orange county with an office in Fullerton, CA

Welcome — Let's Get You the Right Care

Complete this form before your visit so we can focus your appointment on relief, not paperwork.

All information is protected under HIPAA.

Personal Info

Symptoms

Medical History

Consent

Contact Us

Personal Information

Emergency Contact

Your Primary Concern

Symptoms Checklist

Location of Symptoms

Pain Level

Medical History

Current Medications

Prior Treatments

What have you already tried for your neuropathy?

Consent & Privacy

Please read and acknowledge each item

Treatment Consent: I authorize Neuropathy Relief Centers and its licensed providers to perform a clinical evaluation and administer recommended treatments. I understand I may ask questions about any procedure before it is performed and that I may withdraw consent at any time.

HIPAA Privacy Notice: Neuropathy Relief Centers collects and maintains your protected health information (PHI) for treatment, payment, and health care operations. Your information will not be sold or shared with third parties for marketing purposes. You have the right to access, amend, and obtain a copy of your health records. Our full Notice of Privacy Practices is available at our front desk and upon request.

Financial Responsibility: I understand that I am responsible for any charges not covered by my insurance plan, including co-pays, deductibles, and non-covered services. I authorize assignment of insurance benefits to Neuropathy Relief Centers.