Cranial CenterStep 1 of 425%Patient InformationFirst Name(Required)Last Name(Required)Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male FemaleYour Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone(Required)Secondary PhoneYour Email Address(Required) Email Address Confirm Email Address Emergency Contact(Required)Phone(Required)InsuranceThis must be filled out completely.Referring Physician and/or PediatricianDoctor’s Phone NumberDoctor’s Fax NumberInsuranceID#Insured NameInsured 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 QuestionnaireToday'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)SingleMultipleHead DownBreechCesareanVaginalForcepsSuctionWere there any problems during the delivery?(Required)YesNoPlease explainDid you notice anything unusual about the way the baby was positioned in utero?(Required)YesNoPlease explainDoes your baby have any neck tightness?(Required) No YesWhich side? Right side Left sideHave you or a physical therapist used exercises to stretch the neck muscles?(Required) No YesHow many times are the exercises performed each day? 1-2 3-4 5-6 7 or moreHas this seemed to be helpful? No YesDid your baby need to spend long periods of time in one position for the first weeks or months of life?(Required) No YesPlease explainCurrently, in what position does your baby spend most of their time while sleeping?(Required) Back Stomach Right Side Left SideHave you tried repositioning your baby?(Required) No YesHow? Propping with pillows Moving the position of crib in room OtherHas this seemed to be helpful? No YesDid your baby’s head appear to be normally shaped at birth?(Required) No Yes, for a newbornAt 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) No YesHow many?MalePlease enter a number from 0 to 10.How many?FemalePlease enter a number from 0 to 10.Do any of your other children have abnormally shaped heads? No YesDo any of your other children have abnormally shaped heads? No YesNOTICE: PATIENT PRIVACYMarch 1, 2025We 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 FORMPLEASE 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 Email
