We Believe Relief is Within Reach!

Nearest Location
(212) 952-9355

111 Broadway Suite 503

Other Manhattan Locations

24/7 Live Chat Now

  • New Patient Form

    About You


    By checking, you authorize MaxWell Medical to email you about our office and appointments. We will not spam you or share your email address.

    Reasons for visit


    Health History

    Heaart attack/Strokecongenital Heart DefectAlchohal/Drug AbuseHIV+/AidsFrequant Neck PainHigh/Low Blood PressureSevere/FrequentHeadachesFainting/Seizures/EpilepsyDiabetes/tuberculosisLower Back ProblemsHeart surgery/PacemakersMitral valve ProlapseVenereal DiseaseShinglesEmphySema/GlaucomaPsychiatric ProblemsKidney problemsSinus ProblemDifficulity BreathingArtificial Bones/JointsHeart MurmurArtificial ValvesHepatitisCancerAnemiaRheumatic FeverUlcers/ColitisAsthmaChemotherapyArthritis

    • 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 payment in full for all services at the time of visit, unless other arrangements have been made with the managing director. if account is not paid with in 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 collection your account.
    • 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 that it is my responsibility to inform MaxWell Medical, PC of any changes to the information i have provided.

    Signature: ____________________________________

    Date: _____/_____/______

    Disclaimer: Print the form and bring it with you

    Comments are closed.