New Patient Intake and Consult Form

EMPLOYMENT

EMERGENCY CONTACT

HEALTHCARE PROVIDERS

ABOUT YOUR VISIT

PREFERRED COMMUNICATION

HEALTH HISTORY

CHIEF HEALTH CONCERNS

CURRENT MEDICAL CONDITIONS

ALLERGIES

HEALTH & LIFESTYLE ASSESSMENT

FAMILY HISTORY

Please list significant illnesses and the affected relative.

LIFESTYLE

MUSCULOSKELETAL SYMPTOMS

GENERAL HEALTH SYMPTOMS

HEALTH GOALS

FINANCIAL POLICY, AUTHORIZATIONS & ACKNOWLEDGEMENTS

Please review the following information and sign at the bottom of this page.

FINANCIAL POLICY

• Payment is due at the time services are rendered unless other arrangements have been made in advance.
• Most blood testing laboratories bill insurance directly, and laboratory services are generally covered according to your individual insurance benefits.
• Chiropractic services are submitted to your insurance carrier when applicable. We will work with your insurance company if you have out-of-network benefits and your deductible has been met, submit claims upon request, and accept assignment of benefits where applicable. Assignment may cover only part of the claim; you are responsible for any unpaid balance.
• Functional Medicine consultative services are generally not covered by insurance. In certain circumstances, Medical Nutrition Therapy (CPT 97802) and reassessment services may be covered, subject to eligibility and benefits.
• Professional nutritional supplements and retail products are not covered by insurance.
• A $50 cancellation fee may be charged for appointments cancelled with less than 24 hours notice or for missed appointments.

COMMUNICATION AUTHORIZATION

CREDIT CARD AUTHORIZATION

I authorize Dr. Loren Marks to securely maintain my credit card information for payment of professional services, products purchased, outstanding balances, or fees described in this Financial Policy. Credit card charges will appear on my statement as "On The Mark Health & Wellness, Dr. Loren Marks." Checks must be made payable to "Dr. Loren Marks."

HIPAA ACKNOWLEDGEMENT

I acknowledge that I have been offered a copy of the Notice of Privacy Practices for On The Mark Health & Wellness and understand my rights regarding the privacy of my protected health information.

PATIENT AGREEMENT

By signing below, I acknowledge that I have read and understand the Financial Policy, Communication Authorization, Credit Card Authorization, and HIPAA Acknowledgement.

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.

INFORMED CONSENT FOR CARE

Please read this information carefully before signing.

YOUR CARE MAY INCLUDE

• Comprehensive history, physical examination, orthopedic and neurological testing, and functional assessment.
• Chiropractic spinal and extremity adjustments using manual and/or instrument-assisted techniques.
• Rehabilitative exercises, stretching, neuromuscular re-education, and balance training.
• Physiotherapy procedures including electrical stimulation, heat, cold, soft tissue therapy, flexion-distraction, and cervical traction when clinically indicated.
• Clinical nutrition, Functional Medicine consultation, laboratory interpretation, lifestyle counseling, and nutritional supplement recommendations when appropriate.

BENEFITS

• Relief of pain and discomfort.
• Improved mobility, strength, balance, and physical function.
• Support for overall health and wellness through individualized care.

POSSIBLE RISKS

• Temporary soreness, stiffness, fatigue, or aggravation of symptoms may occur.
• Bruising or skin irritation may occur following certain therapies.
• Although uncommon, more significant complications have been discussed and may occur with any healthcare procedure.

ALTERNATIVES

Alternative options include medical care, physical therapy, medications, observation without treatment, or other treatments discussed with your provider.

SPECIALIZED PROCEDURES

Certain specialized procedures, including Non-Surgical Spinal Decompression, Extracorporeal Shockwave Therapy, and ProBalance 360 Balance Rehabilitation, may require additional procedure-specific informed consent before treatment.

PATIENT CONSENT

I have had the opportunity to ask questions regarding my care. My questions have been answered to my satisfaction. I understand the proposed care, its potential benefits, risks, and reasonable alternatives. I voluntarily consent to examination and treatment provided by Dr. Loren Marks and the clinical staff of On The Mark Health & Wellness.