NJHRC HIPAA Authorization Form - New Jersey Headache Relief Center.

HIPAA Authorization Form

Your health information is protected by law. Signing this form grants us consent to use your health information. We use this information to secure stronger insurance reimbursement whenever possible.

NJHRC Patient Intake Form - New Jersey Headache Relief Center.

New Patient Intake Form

This form is used to collect contact information for you and your spouse (if applicable), emergency information, and your information about your dental and medical history.

NJHRC Head Health History Form - New Jersey Headache Relief Center.

Head Health History Form

This questionnaire is used to capture critical information vital about your head health history, dental work you’ve had that relates to your dental forces, pain symptoms and locations, traumatic accidents, lifestyle and habits.

Notice of Privacy Practices - New Jersey Headache Relief Center.

Notice of Privacy Practices

Please read this document as it describes how health information about you may be used and shared, and how you can access this information. Your privacy is important to us!

Headache History Form - New Jersey Headache Relief Center.

Headache History Form

This questionnaire is used to collect information about your health and headache history, including any previous diagnoses and testing, medications you’ve taken, pain locations, severity and intensity.