Intake - Cranial Center

Cranial Center

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Patient Information

First Name(Required)

Last Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Preferred Language(Required)

Name of Parent/Guardian(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Your Email Address(Required)

Email Address Confirm Email Address

Emergency Contact(Required)

Phone(Required)

Insurance

This must be filled out completely.

Referring Physician and/or Pediatrician

Doctor’s Phone Number

Doctor’s Fax Number

Insurance

ID#

Insured Name

Insured DOB

MM slash DD slash YYYY

Consent(Required)

I, understand that custom fabrication items are not returnable or refundable due to the nature of the work. I understand that if my insurance requires authorization and I choose to receive service before written authorization is received that I will accept full financial responsibility. I understand authorization is not a guarantee of payment from the insurance company. There will be a charge of $100.00 for any missed appointments without 24-hour notice. I understand all appointments are well visits and must be rescheduled if the baby or parent/guardian are not feeling well/sick and will be turned away if they arrive sick.

I agree.

Medical Questionnaire

Today's Date(Required)

MM slash DD slash YYYY

Patient Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Birth Length(Required)

Please enter a number from 5.00 to 30.00.

Birth Weight(Required)

Please enter a number from 0.00 to 20.0.

Number of Weeks at Birth(Required)

Please enter a number from 10 to 42.

Type of Birth(Required)

Were there any problems during the delivery?(Required)

Please explain

Did you notice anything unusual about the way the baby was positioned in utero?(Required)

Please explain

Does your baby have any neck tightness?(Required)

Yes

Which side?

Right side

Left side

Have you or a physical therapist used exercises to stretch the neck muscles?(Required)

Yes

How many times are the exercises performed each day?

1-2

3-4

5-6

7 or more

Has this seemed to be helpful?

Yes

Did your baby need to spend long periods of time in one position for the first weeks or months of life?(Required)

Yes

Please explain

Currently, in what position does your baby spend most of their time while sleeping?(Required)

Back

Stomach

Right Side

Left Side

Have you tried repositioning your baby?(Required)

Yes

How?

Propping with pillows

Moving the position of crib in room

Other

Has this seemed to be helpful?

Yes

Did your baby’s head appear to be normally shaped at birth?(Required)

Yes, for a newborn

At what age did you first notice your baby’s head was abnormally shaped?(Required)

Please enter a number from 0 to 10.

Do you have other children?(Required)

Yes

How many?

Male

Please enter a number from 0 to 10.

How many?

Female

Please enter a number from 0 to 10.

Do any of your other children have abnormally shaped heads?

Yes

Do any of your other children have abnormally shaped heads?

Yes

NOTICE: PATIENT PRIVACY

March 1, 2025

We are committed to preserving the privacy of your personal health information. In fact, we are required by law to protect privacy of your medical information and to provide you with Notice describing:

Consent(Required)

HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION
We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.

We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization. As a patient, you have the important rights relating to inspecting and copying your medical information that we maintain, amending or correcting that information, obtaining a accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

We have available a detailed Notice of Privacy Practices which fully explains your rights and our obligations under the law. We may revise our Notice from time to time. The effective date at the top right hand side of this page indicates the date of the most current Notice in effect.

You have the right to receive a copy of our most current Notice in effect. If you have not yet reserved a copy of our current Notice, please ask at the front desk and we will provide you with a copy.

If you have any questions, concerns or complaints about the Notice of your medical information please contact:

Pat Casamassima of our office at (732) 739-0888.

I agree.

Signed(Required)

Date(Required)

MM slash DD slash YYYY

PHOTO RELEASE FORM

PLEASE READ THROUGH THIS FORM AND FILL OUT ACCORDINGLY.

Name

First Last

Select

I am allowing Cranial Center to use photos of my child in our marketing materials, social medias, and website (dispense and graduation celebrations).

I am not allowing Cranial Center to use photos of my child.

Name

First Last

MISSED APPOINTMENT & NO-SHOW POLICY

Your appointment is very important to us. We understand that sometimes schedule adjustments are necessary. Therefore, we respectfully request at least 24 hours’ notice for cancellations. Please be aware that any cancellation or no show without 24-hour notice will result in a $100 charge to your account. Please provide credit card information below to keep on file along with your signature. Thank you.

Consent(Required)

I agree to the MISSED APPOINTMENT & NO-SHOW POLICY

Your appointment is very important to us. We understand that sometimes schedule adjustments are necessary. Therefore, we respectfully request at least 24 hours’ notice for cancellations.
Please be aware that any cancellation or no show without 24-hour notice will result in a $100
charge to your account.
Please provide credit card information below to keep on file along with your signature.

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Credit Card #(Required)

Expiration Date(Required)

CVV Code(Required)