Schedule a New Patient Appointment

Fields marked with a red asterisk (*) are required, enter N/A when a mandatory field is not applicable. Upon submission of this form, a representative from our New Patient Department will contact you within two business days. If you prefer, please feel free to contact our New Patient Department directly for assistance at 1-800-HEADACHE.

Patient Demographics

Patient First Name *

Patient Middle Name

Patient Last Name *

Patient Sex *

Patient Date of Birth *

Year

Month

Day

Patient Full Address (Street, City, State, Zip Code, Country) *

Patient Home Phone *

Patient Work Phone

Patient Mobile

Patient Email

Patient Contact Preference

Patient Preferred Language

Patient Race (Hold Ctrl/ Cmd to Select Multiple)

Patient Ethnicity

Patient Marital Status

Patient Current Employment Status

Emergency Contact Demographics

Emergency Contact Last Name (Person NOT living with you) *

Emergency Contact First Name (Person NOT living with you) *

Emergency Contact Middle Initial (Person NOT living with you)

Emergency Contact Relationship to Patient *

Emergency Contact Home Phone *

Emergency Contact Work Phone

Emergency Contact Mobile

Emergency Contact Full Address (Street, City, State, Zip Code, Country)

Responsible Party (Guarantor)

Responsible Party Last Name *

Responsible Party First name *

Responsible Party Middle Initial

Responsible Party Relationship to Patient *

Responsible Party Sex *

Responsible Party Date of Birth *

Year

Month

Day

Responsible Party Home Phone *

Responsible Party Full Address (Street, City, State, Zip Code, Country) *

Responsible Party Current Employment Status

Primary Insurance Coverage

Primary Insurance Name *

Primary Insurance Type *

Primary Insurance Effective Date

Year

Month

Day

Primary Insurance ID *

Primary Insurance Group Number (if applicable)

Primary Insurance Phone *

Primary Insurance Covered through

Primary Insurance Employer Size (if applicable)

Primary Insurance Subscriber Last Name *

Primary Insurance Subscriber First Name *

Primary Insurance Subscriber Middle Initial

Primary Insurance Subscriber Date of Birth *

Year

Month

Day

Primary Insurance Subscriber Relationship to Patient *

Primary Insurance Subscriber Full Address (Street, City, State, Zip Code, Country) *

Primary Insurance Subscriber Home Phone *

Primary Insurance Subscriber Current Employment Status

Secondary Insurance Coverage

Secondary Insurance Name

Secondary Insurance Type

Secondary Insurance Effective date

Year

Month

Day

Secondary Insurance ID

Secondary Insurance Group Number (if applicable)

Secondary Insurance Phone

Secondary Insurance Covered Through

Secondary Insurance Employer Size (if applicable)

Secondary Insurance Subscriber Last Name

Secondary Insurance Subscriber First Name

Secondary Insurance Subscriber Middle Initial

Secondary Insurance Subscriber Date of Birth

Year

Month

Day

Secondary Insurance Subscriber Relationship to Patient

Secondary Insurance Subscriber Full Address (Street, City, State, Zip Code, Country)

Secondary Insurance Subscriber Home Phone

Secondary Insurance Subscriber Current Employment Status

Referral Information

Referral Source

Referring Physician Name

Referring Physician Specialty

Referring Physician Work Phone

Referring Physician Full Address (Street, City, State, Zip Code, Country)

Patient Headache History

In the last year, have you ever been hospitalized for headaches? *

In the last six months, have you gone to the emergency room for headache treatment? *

Are you taking five or more medications for your headache? *

For over six months, have you been taking medications daily to abort your headaches? *

Have you seen more than two physicians for your headaches? *

Do you have headaches more than 15 days each month? *

In the past year, have you had an abnormal result for MRI of the head? *

Have you been diagnosed as Bipolar or Borderline? *

Scheduling Preference

Appointment Day Preference (Hold Ctrl/ Cmd to Select Multiple)

Appointment Time Preference (Hold Ctrl/ Cmd to Select Multiple)

Appointment Location Preference (Hold Ctrl/ Cmd to Select Multiple)

1460 N HALSTED ST STE 501
CHICAGO, IL 60642

1-800-HEADACH

1-800-432-3224

1-773-388-6390

Schedule An Appointment

*Diamond Headache Clinic’s goal is to rehabilitate, restore and improve function and independence, as well as to reduce the effects of the condition. Results may differ and no claims, promises or guarantees are being made or implied about the average, typical or expected results.