Sports Medicine | New Patient Registration

Personalized Care ♟ Sports Medicine

Let's get to know you...in private.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Submission Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Patient Gender (at birth)*
Patient E-Mail*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Preferred Method of Contact

EmailTextGood Old Fashioned Phone Call
Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the Sports Medicine concerns you wish to address:*

Acute Injuries (sprains, strains, fractures, dislocations, contusions)Chronic Injuries (tendinitis, stress fractures, shin splints, chronic joint or muscle pain)Overuse Injuries (runner's knee, plantar fasciitis, swimmer's shoulder, tennis elbow)Performance Optimization (fitness assessments, nutrition counseling, personal training)Rehabilitation (post-surgery rehabilitation, physical therapy)Other
Please describe other:
Are you currently under the care of a physician for any injuries?*

YesNoMy doctor referred me to Checkmate Health
Are you currently taking any prescription medications related to sports medicine?*

YesNo
Please list the medications you are currently taking:
What type of Sports Medicine services are you looking for with Checkmate?*

Injury Diagnosis/ManagementDiagnostic Testing (ie: EKG, ECHO)Imaging Services (X-ray, MRI, CT Scans, Ultrasound)Injection Therapies (corticosteriods, PRP)Lab Work/Blood TestsPhysical TherapyPain ManagementPersonal TrainingRegenerative Medicine (Stem Cells, Exosomes)Orthotic Evaluation (splinting, braces)Orthopedic CareAn at-home physical assessment/examination or consultation is neededI'm not sure and need help figuring out what's needed.Other (not listed here)
Other:
Please upload any orders or forms from your medical doctor or surgeon:

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Why cover the whole bill if you don't have to? Upload the front and back of your insurance card here and we'll check to see if any services are covered :)

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We want to put a face to your name. Please upload the front and back of your photo ID here:

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Medical History

We care about you...
Have you ever had (Please check all that apply)

NoneAnemiaAsthmaArthritisBleeding DisordersCancerGoutDiabetesEmotional DisorderEmphysemaEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseLung DiseaseNeurological DisordersSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseOther
Other illnesses:
Do you have any allergies?*

YesNo
Please list your allergies:
Do you take any blood thinners/anticoagulant?*

YesNo
Are you taking any medications?*

YesNo
Please list your current medications:
Have you ever had surgery?*

YesNo
Please list surgical procedures & dates of each:
Healthy & Unhealthy Habits

No judgements, offering improvements upon request...
Exercise

Never1-2 days3-4 days5+ days
Eating habits/following a diet

I have a loose dietI have a strict dietI eat generally healthy, but I could make improvementsI don't have a diet plan
Alcohol consumption

I don't drinkI am a social drinker (less than 5 drinks/week)1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Do you Vape?

YesNo
Are there any other elements or substances in your routine?

CaffeineMarijuanaMagic MushroomsCocaineMDMA and/or 2CBLSDMethamphetamine
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO THIRD PARTY PURSUANT TO HIPAA

This authorization indicates a disclosure of information pertaining to medical records and the release of official laboratory results/treatment to a third party for the intended medical reasons. I, the patient, allow Kings Medical Services P.C. to release any/all results and reports from my pre-surgical testing to my medical doctor, surgeon, and/or the affiliates involved in my healthcare and sports medicine care plan.

I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form to only those agreed upon for my care.

Kings Medical Services P.C. AUTHORIZATION TO GIVE MEDICAL CARE – CONSENT TO TREATMENT:

I hereby voluntarily consent to treatment and care from all medical personnel contracted with Kings Medical Services P.C. I further consent to the performance of any diagnostic procedures, examinations, laboratory tests and rendering of medical treatment by Kings Medical Services' medical providers and staff, as is necessary in the medical staff’s judgment. I understand that this consent will be valid and remain in effect as long as I am a patient with Kings Medical.
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Date

MonthDayYear
Date

Booking Deposit Payment*

DepositNon-Refundable. Pay remainder at time of booking.

$75.00

Enter coupon

Total

$0.00

Appointment
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Personalized Care ♟ Sports Medicine

Medical History

Healthy & Unhealthy Habits