Chiropractic Patient Intake Form - Dr. Nicholas Carlisle

Please check which office for treatment

Atlanta/Sandy Springs, Ga

Jonesboro, Ga

Patient Information

First Name:

Last Name:

Date of Birth

Social Security #:

Email Address:

Address (Home):

City:

State

Zip Code:

Phone (Mobile):

Phone (Home):

Employer Name:

Employer Phone Number:

Emergency Contact

First Name:

Last Name:

Phone:

Relationship:

Phone Type:

Home Mobile Work Other

Health Insurance Information

Do You Have Health Insurance?

Yes No (Skip to Complaint Summary Section)

Health Insurance Company Name:

Member-Policy ID/#:

Member-Policy Group #:

Social Security #:

Insurance Plan (i.e. HMO, PPO, etc.):

Provider/Customer Service Phone Number (Back of the card):

Responsible Party Information/Policy Holder

Relationship to Patient:

Self (Skip to next section) Spouse Parent Other

First Name:

Last Name:

Date of Birth

Social Security #:

Address:

City:

State:

Zip Code:

Phone (Mobile):

Phone (Home):

Relationship to Patient:

Accident Information

Is condition due to an accident? (Car Accident or Slip & Fall?)

Yes No (Skip to Complaint Summary Section) N/A (Skip to Complaint Summary Section)

Type of accident?

Auto Work Home Slip & Fall Other No Accident

Date of Accident

City & State of Accident

Attorney's Name (if applicable)

Attorney's phone number (if applicable)

Attorney's fax number (if applicable)

Attorney's email address (if applicable)

Medical Payment Coverage Information (Car Accident)

Do You Have Medical Payment Coverage (Med Pay) on your car insurance?

Yes No (Skip to Complaint Summary Section) N/A (Skip to Complaint Summary Section) No Accident (Skip to Complaint Summary Section)

Car Insurance Company Name:

Claim Number:

Policy Number:

Adjuster name:

Adjuster Phone Number:

Dollar amount of coverage (if known):

Complaint Summary:

Describe Complaint:

Date of injury

How and When Did it Begin?

Severity of your pain on a scale from 1 (least) to 10 (worst):

If Other Chosen Above, Please Explain Below:

Frequency of Complaint

Constant

Intermittent

If Other Chosen Above, Please Explain Below:

Does the pain interfere with:

Work

Sleep

Recreation

Daily Routine

Exercise

Other Daily Activities Most Affected by this Complaint:

Does you pain cause headaches? Do you have a history of heaches? Yes or No? Please Explain Below:

List Any Doctor/Facility you have gone to for treatment of your injuries: (ER/MD/PT/Chiro/Other/None)

List Any Treatment You Have Received for This Complaint: (ER/MD/PT/Chiro/Other/None)

List Any Self Treatment: (Ice/Heat/Stretching/Medication/Massage/Rest/Soaking/Other/None)

Have You Taken Any Medications or Prescribed Medication for your condition?

Yes No

If You Answered ‘Yes’ Above, Please List What You Have Taken (Prescriptions or OTC):

Have You Had Any Diagnostic Testing Performed for Above Complaint?

X-Ray(s)

MRI

CT Scan

Ultrasound

NCV

Other

No Tests Have Been Performed

If Other Chosen Above, Please Explain Below:

Health Summary

Please List Current Medications Including How Often and Dosage

Any Allergies to Any Medications (List Below):

Relevant Major Health Problems in Your Immediate Family:

List Any Major Surgeries Received and Date:

Informed Consent for Chiropractic Care

When a patient (PT) seeks chiropractic health care, it is essential that the PT and chiropractic health care Provider (Chiropractor) work for the same objective. It is also important that each PT understand both the objective and the method that will be used to attain the desired results in order to prevent any confusion or disappointment. As a PT, you have the right to be informed about the condition of your health, the recommended care and treatment to be provided and the known benefits, risks and alternatives, so that you can make the decision whether or not to undergo chiropractic care.

Chiropractic is a science and art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) and how that relationship my effect the restoration and preservation of health. Health is the state of optimal physical, mental and social wellbeing, not just the absence of disease and infirmity. One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24 vertebrae in the spinal column become misaligned and do not move properly. This causes alteration of the nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic.

Subluxations are corrected and reduced by a chiropractic adjustment, which is a specific application of force to correct or reduce vertebral subluxation. Adjustments are usually done by hand, but may be performed by handheld instruments. In addition, ancillary procedures, such as physiotherapy or rehabilitation procedures may be included.

If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider. Any procedure intended to help, may also do harm. While chiropractic examination, manipulation, and therapeutic procedures are considered remarkably safe and effective, please understand that occasionally there may be adverse reactions. Although the chances of experiencing any of these complications are extremely small, it is the practice of Atlanta Medical Institute (AMI) & Atlanta Spinal Health (ASH) to fully inform and educate all of our guests.

By signing below, I understand that these complications may include, but are not limited to, muscle strains and sprains, fractures, dislocations, disc injuries, and strokes. I do not expect he doctor to be able to anticipate or explain all possible risks and complications. I wish to rely on the doctor(s) to exercise judgment during the course of my treatments that he/she feels are in my best interest based upon the facts know at the time of treatment. I understand that there is no guarantee or warranty for a specific cure or result. I understand that at any time, I can request further explanation regarding risks and benefits of care in this facility, alternative courses of care, and the consequences of not having the proposed treatment.

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Signature check box

Date

Consent to Evaluate and Adjust a Minor Child (if applicable)

I have read and fully understand the informed consent and hereby grant permission for my child to receive chiropractic care.

Parent or Legal Guardian Name

Name of Minor

Financial Policy Agreement

Thank you for selecting Atlanta Medical Institute (AMI) and Atlanta Spinal Health (ASH) for your health care needs. We are pleased to be of service to you and your family. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept Visa, MasterCard, American Express, and cash. By signing this Financial Policy Agreement, I agree: Should this account be referred to an agency or an attorney for collection that I will be responsible for all collection costs, attorney's fees and court costs.

As a courtesy, we bill your insurance company directly. However, the insurance and or settlement checks may be sent to you and made out in your name. Accordingly, please read and sign the following agreement details:

I agree to bring these checks to Atlanta Medical Institute (AMI) or Atlanta Spinal Health (ASH)

I agree not to tear apart the check from the Explanation of Benefits

I agree to sign funds over to AMI or ASH for services received

I further instruct my attorney and/or car insurance company, whomever it may be at the conclusion of my personal injury claim, to withhold the amount of my outstanding balance owed to Atlanta Medical Institute (AMI) or Atlanta Spinal Health (ASH) out of the proceeds of my personal injury claim and to pay these amounts owed by me directly to Atlanta Medical Institute (AMI) or Atlanta Spinal Health (ASH) without first paying these sums to me. These instructions to my attorney and/or car insurance company are made in consideration of Atlanta Medical Institute’s and Atlanta Spinal Health's willingness to suspend efforts to collect the entire amount owed by me to Atlanta Medical Institute and Atlanta Spinal Health until such time as my personal injury claim is resolved, and any subsequent efforts by me to revoke these instructions shall be considered null and void. (For patients treated for car accident and slip & fall injuries. This does not apply to health insurance or self pay patients.)

I understand that if I fail to deliver payments or settlement received from the insurance company to AMI or ASH within 3 business days of receipt, I will be responsible for the entire amount billed. I have read, understand and agree to the above written responsibility on my part as your patient.

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Date

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