New Patient Forms

Required For Your Case History File

Dr.

File #

Name

Date

X-ray #

Address

City

State

Zip

Telephone

Social Security No

Age

Birthdate

Sex

No. Children

Occupation

Employer

Yrs. Employed

Employer's Address

Work Phone

Spouse's Name

Occupation

Employer

Person responsible for this account

Referred by

INSURANCE INFORMATION:

Are you covered by Medicare?

Yes No

Medi·Cal?

Yes No

County

Do you have any group, union or personal health and accident insurance?

Yes No

Name of Insurance Company

Claim No

Address

Agent

Is your condition due to an accident or illness

Did your accident occur while at work?

Yes No

When

Were you involved in an automobile accident

Yes No

When

Cash payment

Other

What is your major complaint?

Other complaints

How long have you had this condition?

Have you had this or similar conditions in the past?

What activities aggravate your condition?

Is this condition interfering with your:

Work

Sleep

Daily Routine

Other

If other, specify:

How long has it been since you really felt good?

Other doctors who treated this condition

List surgical operations and years:

Drugs you now take:

Nerve pills

Insulin

Pain killers

Birth control pills

"Pep" pills

Tranquilizers

Other

Dental visits:

Every 6 months Yearly Toothache or "emergency" only Complete Dentures

Age of mattress

Comfortable Uncomfortable

Do you use a bed board?

Are you wearing:

Heel lifts

Sole lifts

Inner soles

Arch supports

Have you been in an auto accident?

Past year Past 5 years Over 5 years Never

Describe

Have you had any other personal injury or accident?

Past year Past 5 years Over 5 years None

Describe

Have you ever had any mental or emotional disorders?

Yes No

When?

Have others in your family had such disorders?

Yes No

When?

FAMILY HEALTH INFORMATION

(Many health problems are the result of hereditary spinal weaknesses; thus information about your family members will give us a better picture of your total health picture.)

AddName

I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature:

Email:

Date:

Guardian or Spouse's Signature Authorizing Care:

Date:

ASSIGNMENT

I hereby instruct and direct my insurance company to pay by check made out and mailed directly to this clinic the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered by this clinic.

A photocopy of this assignment shall be considered as effective and valid as the original.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature:

Date:

RELEASE OF INFORMATION

I authorize this clinic to release any information pertinent to my case to any insurance company, adjustor, and attorney involved in this case; and hereby release this clinic of any consequence thereof.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature:

Date:

FINANCIAL RESPONSIBILITY

I agree to be financially responsible for all charges incurred at this clinic including my insurance deductible, copayment and any services rejected by my insurance company.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature:

Date:

Completed

DXs entered

File #

EHR History & Examination

1. Demographics

Don't know/ prefer not to say

If other, specify:

2. Would you like an e-mail reminder of upcoming appointments?

Yes No

(please initial)

I hereby give my consent to have my health records available to me via a secure, web-based portal.

3. Are you taking any medications?

Yes No

If yes, please list medications (be specific) you are currently taking along with dosage. *If you have a med list, we can copy it for you instead.

Add new row

4. Are you allergic to any Medications?

Yes No

If yes, please list medications you are allergic to and the problem experienced, along with the level of severity (mild, moderate, severe):

Add new row

5. Do you smoke now?

Yes No

Have you ever been a smoker?

Yes No

Do you use any other form of Tobacco?

Yes No

If a current tobacco user, please complete the following:

What type

How much

Have you tried to quit?

Yes No

What methods did you use

DOCTOR ONLY

*Vital Signs

height

weight

Pulse

DX:
Children 18 yo growth chart

check list
Social/Family Hx
Problem list

CHIROPRACTIC INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic procedures, including various modes of physio therapy, diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures.

I understand and I am informed that, as is with all Healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all Healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests.

I further understand that Chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations allowing the body to return to improved health. It can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures. However, like all other health modalities, results are not guaranteed and there is no promise to cure. Accordingly, I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment.

I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited self-administered, over the counter analgesics and rest; medical care with prescription drugs such as anti-inflamrnatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and 'secure other opinions if I have concerns as to the nature of my symptoms and treatment options.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Name of Patient:

Signature of Patient:

Name Printed of Guardian/Parental

Relationship to Patient

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Guardian/Parental Signature:

Date:

Doctor of Chiropractic Name:

Signature of Doctor of Chiropractic:

Date:

ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE

I have received a copy of this office's Notice of Privacy Practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the health care providers who may be directly and indirectly involved in providing my treatment.

Obtain payment from third-party payers.

Conduct normal health care operations such as quality assessments and accreditation.

Name of Patient or Personal Representative

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Personal Representative

Relationship

Date:

For Office Use Only

We attempted to obtain written Acknowledgment of receipt of our Notice of Privacy Practices, but Acknowledgment could not be obtained because:

We attempted to obtain written Acknowledgment of receipt of our Notice of Privacy Practices, but Acknowledgment could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the Acknowledgment

An emergency situation prevented us from obtaining Acknowledgment

Other

If other, Please Specify:

Staff signature:

Date:

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