Mid-Atlantic Brain and Neurological Rehabilitation offers our patient form(s) online so they can be completed in the convenience of your own home or office.
- Download the necessary form(s), print it out and fill in the required information.
- Fax us your printed and completed form(s) or bring it with you to your appointment.
For First Visits, REQUIRED Forms
- HIPAA Policy
- HIPAA Release
- Consent to Services (PDF)
- Consent to Services (Word)
- Medical Authorization Form
- Patient Information Sheet (PDF)
- Patient Information Sheet (Word)
- Patient Notification of Financial Responsibility
- Intake Form (PDF)
For First Visits (Children Only)
- HIPAA Policy
- HIPAA Release
- Consent to Services (PDF)
- Consent to Services (Word)
- Patient Information Sheet (PDF)
- Patient Information Sheet (Word)
- Intake Form (PDF)
- Child's Consent Form
- New Childhood Intake Form
Other Forms ONLY Fill Out These as Directed
- Accidental Fall Intake Form
- Brain Region Localization Form
- Comprehensive Health History Form
- Mental and Mood History Intake Form
- Metabolic Assessment Form
- MVA Intake Form
- Neurotransmitter Assessment Form
- Patient Narrative Instructions
- Patient Narrative Sample 1
- Patient Narrative Sample 2
- Post-Concussion Symptoms Questionnaire
- Vestibular Intake Form
- LightForce Informed Consent
- LightForce Patient Intake Form
Specialty Forms
Neurotransmitter and Metabolic Assessment Forms In addition to the new patient examination, you may be directed to complete specialty forms which help assess such aspects as general brain function, the influence of stress and blood sugar imbalance on your brain, general gut function, adrenal function, thyroid function, neurotransmitter regulatory issues, or a host of other considerations.
Additional Lab Panels At times, it may be necessary to order comprehensive blood chemistry reports in determining how to manage your condition most appropriately. Other lab panels such as adrenal, hormonal, stool and immune panels may be helpful as well. For instance, immune problems and gut issues can severely impact overall brain function.
