111 Broadway, Suite
1301, New York, NY 10006
New Patient Form
We welcome new patients and your new patient intake at MaxWell Medical is simple and secure. Anything we can do to make your patient experience seamless at our therapy clinics is very valuable to us. Hence, we focus on a swift registration before your medical appointment.
Personal Information
Reason for Visit
In Case of Emergency
Health History
01
Personal Information
Please fill in your personal details accurately.
02
Reason for Visit
Tell us about your condition and rate your pain areas.
Rate area of pain on a scale of 1-10.
10 being the worse.
03
In Case of Emergency
Please provide emergency contact information.
04
Health History
Please provide your medical background accurately.
- We invite you to discuss with us any questions regarding our services. The best health services are based on friendly, mutual understanding between provider and patient.
- Our policy requires full payment for all services at the time of visit unless other arrangements have been made with the Managing Director. If account is not paid within 90 days of the date of service and no financial arrangements have been made, your will be resposible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.
- Our missed appointment policy requires a credit card on file. In the event that there is no notification for missing an appointment, we are authorized to charge your credit card $25 fee.
- I authorize staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider and/or managed care organization, to release any information required to process insurance claims.
- I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform MaxWell Medical of any changes to the information I have provided.
This disclaimer governs your use of MaxWell Medical. Please read it carefully before using this website.
Your use of this site indicates your acceptance of this disclaimer in full. If you disagree with any part of it, please immediately navigate away from this website.
All the content provided on this site is created only for informational purposes and is not intended to be a substitute for in-person evaluation, diagnosis, care, or treatment by a qualified healthcare professional.
Therefore, do not disregard professional medical advice or delay in seeking it from your primary care physician or any other healthcare professional because of anything you have read here. If you choose to rely on any information contained in this site, you will be doing so at your own risk.
You are advised to consult with your primary care physician regarding your symptoms, condition, medications, or treatment.
If you suspect that you may have a medical emergency, call your primary care physician or a local healthcare provider or visit the emergency department of your nearest hospital.
Links to external websites or educational content that is not created by us are taken at your own risk. We, under no circumstances, are responsible for the information provided by any third-party website or the claims made by an educational provider.
We reserve the right to make changes in this disclaimer at any time without prior notice. Therefore, you are recommended to visit this page periodically to make sure that you are fully aware of any changes. Your continued use of this site after any such change is posted will be considered your acceptance of it, whether or not you have reviewed it.
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