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Gordon Kuang, Chiropractor
Jialei Tang, Acupuncturist
David Quintero, Chiropractor
Katarzyna Sala, DC, Chiropractor
Mihyun Park, Acupuncturist
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Acupuncture
Body Pain
Ankle/Foot Pain
Knee Pain
Neck & Back Pain
Shoulder Pain
Hip Pain
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Providers
Gordon Kuang, Chiropractor
Jialei Tang, Acupuncturist
David Quintero, Chiropractor
Katarzyna Sala, DC, Chiropractor
Mihyun Park, Acupuncturist
Services
Acupuncture
Body Pain
Ankle/Foot Pain
Knee Pain
Neck & Back Pain
Shoulder Pain
Hip Pain
Chiropractic Care
Infertility
Massage Therapy
Neuropathic Pain
Sciatica
Headaches/Migraines
Scoliosis
Locations
Insurance
Testimonials
Contact Us
Patient Intake Form
More
Patient Education
Blog
Book Now
Home
Providers
Gordon Kuang, Chiropractor
Jialei Tang, Acupuncturist
David Quintero, Chiropractor
Katarzyna Sala, DC, Chiropractor
Mihyun Park, Acupuncturist
Services
Acupuncture
Body Pain
Ankle/Foot Pain
Knee Pain
Neck & Back Pain
Shoulder Pain
Hip Pain
Chiropractic Care
Infertility
Massage Therapy
Neuropathic Pain
Sciatica
Headaches/Migraines
Scoliosis
Locations
Insurance
Testimonials
Contact Us
Patient Intake Form
More
Patient Education
Blog
Menu
Home
Providers
Gordon Kuang, Chiropractor
Jialei Tang, Acupuncturist
David Quintero, Chiropractor
Katarzyna Sala, DC, Chiropractor
Mihyun Park, Acupuncturist
Services
Acupuncture
Body Pain
Ankle/Foot Pain
Knee Pain
Neck & Back Pain
Shoulder Pain
Hip Pain
Chiropractic Care
Infertility
Massage Therapy
Neuropathic Pain
Sciatica
Headaches/Migraines
Scoliosis
Locations
Insurance
Testimonials
Contact Us
Patient Intake Form
More
Patient Education
Blog
Patient Intake Form
Home
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Patient Intake Form
First Name
Last Name
Date of Birth
Cell
Email
Age
Address (please include Apt number if any)
City
State
Zip Code
Ethnicity
Hispanic
White alone, non-Hispanic
Black or African American alone, non-Hispanic
American Indian and Alaska Native alone, non-Hispanic
Asian alone, non-Hispanic
Native Hawaiian and Other Pacific Islander alone, non-Hispanic
Some Other Race alone, non-Hispanic
Multiracial, non-Hispanic
Others
Visit Reason(s)- More than one can be selected
Neck Pain
Neck Pain during Pregnancy
Shoulder Pain
Back Pain
Back Pain during Pregnancy
Lower Back Pain / Lumbago
Knee Pain
Leg Pain
Foot and Ankle Pain
Hip Pain
Hip Pain during Pregnancy
Arthritis
Elbow Pain
Heel Pain
Carpal Tunnel Syndrome
Insomnia
Sciatica
Acne
Anxiety
Arm Pain
Bell's Palsy
Buttock Pain
Calf Strain
Cluster Headache
Constipation
Depression
Dizziness
Frozen Shoulder
Gallstone Pain
Hand Pain
Headache
High Blood Pressure / Hypertension
Infertility
Jaw Pain
Low Blood Pressure / Hypotension
Migraine
Morning Sickness
Muscle Pain
Nausea and Vomiting
Osteoarthritis
Pain in Extremities
Pelvic Pain
Sacroiliac (SI) Joint Pain
Sleep Disorder
Sports Injury
Stomach Ulcer
Stress
Tailbone Pain
Temporo-Mandibular Joint (TMJ) Pain
Tendonitis
Tics / Tourette Syndrome
Tiredness / Fatigue
Weight Loss Consultation
Wrist Pain
Others
Where / Who did you hear about us from? (from menu)
Google
Zocdoc
Friend / Family member refers
Other
Insurance company
Aetna
Blue Cross Blue Shield
Cigna
United Healthcare
Empire Plan NYSHIP
UMR
Meritain Health
Others
ID#
Group#
Social Security#
Gender
Male
Female
Other
Marital Status
Single
Married
Widowed
Divorced
Occupation and weekly hours you work
Emergency Contact’s Name:
Emergency Contact's Phone:
Have you had acupuncture before:
Yes
No
Have you had chiropractic before:
Yes
No
Have you had physical therapy before:
Yes
No
Are you currently pregnant?
Yes
No
No Sure
HIV
Yes
No
No Sure
Hepatitis
Yes
No
No Sure
OTHER SIGNIFICANT HEALTH INFORMATION:
List/Describe areas of pain
Insurance Details
Upload the front of Insurance card:
Upload the back of Insurance card:
SUBMIT INTAKE FORM
Apex Health Midtown
280 Madison Ave, Suite 800, NY 10016
CLICK TO CALL (212) 242-3210
Apex Health Downtown
217 Broadway, Ste. 508, Downtown
CLICK TO CALL (646) 952-0366