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3500 Nostrand Ave, Brooklyn, NY 11229

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Confidential Information Form


Dear Patient,

Please complete this questionnaire. Your answers will help us determine the most effective course of treatment. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. Thank You.


General Practitioner
Physical Therapist
Do You Suffer From: Headaches Neck Pain Arm or Shoulder Pain Back Pain Hip or Leg Pain Chest Pain Abdominal Pain Sinus Trouble Heart Trouble Palpitation Poor Circulation High or Low Blood Pressure Female Problems Prostate Disorder Kidney Problems Bladder Problems Lung or Bronchial Disorder Digestive Disorder Constipation Loose Stool Diabetes Swollen Joints Insomnia Dizziness Numbness Nervousness Depression General Fatigue Morning Fatigue Anemia Poor Memory Hot Flashes


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that HEALTHQUEST/FINALLY HEALTH MEDICAL SERVICES will prepare any necessary reports and forms to assist me making collection from the insurance company and that any amount authorized to be paid directly to the above office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

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