Chiropractic Client Intake Form

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

Insurance Information

Do You Have Insurance?

Yes No (Skip to Complaint Summary Section)

Policy Holder

First Name:

Last Name:

Date of Birth:

Phone (Mobile):

Phone (Home):

Home Address:

City:

State:

Zip Code:

Insurance Company Name:

Policy ID/#:

Policy Group ID/#:

Social Security #:

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

Relationship to Patient:

Do you Have Medical Coverage?

Employer Name (Policy Holder):

Employer Phone (Policy Holder):

Responsible Party Information

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):

Employer Name:

Employer Phone:

Complaint Summary:

Describe Complaint:

How and When Did it Begin?

If Other Chosen Above, Please Explain Below:

Frequency of Complaint

Intermittent

Occasional

Frequent

Constant

If Other Chosen Above, Please Explain Below:

List Daily Activities Most Affected by this Complaint:

List Any Treatment You Have Received for This Complaint:

Have You Taken Any Medications?

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)

CT Scan

MRI

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:

Please indicate your area(s) of pain on the figure below:

PATIENT CONSENT TO X-RAY

I, (Input Name below), authorize the performance of diagnostic x-ray examination of myself which FIRST WELLNESS may consider necessary or advisable in the course of my examination and treatment.

authorize the performance of diagnostic x-ray examination of my child, ward

which FIRST WELLNESS may consider necessary or advisable in the course of examination and treatment.

The patient is a minor, (Input Patient age below) years of age.

My relationship to this minor is

VERIFICATION OF NON- PREGNANCY

This is to certify that, to the best of my knowledge, I am not pregnant and FIRST WELLNESS has my permission to perform diagnostic x-ray examination. I have been advised that x-rays can be hazardous to an unborn child.

Date of last menstrual cycle.

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.

Signed

Date

INFORMED CONSENT

I hereby authorize physicians and staff at First Wellness Family Chiropractic to treat my condition as deemed appropriate.

It is understood and agreed that the amount paid the doctor for x-rays is for examination only and the x-ray films will remain the property of this office, being on file where they may be seen at any time. The doctor will not be held responsible for any pre-existing medically diagnosed condition(s).

I will not hold the doctor or any staff member of First Wellness Family Chiropractic responsible for any errors or omissions regarding my current complaints or past history that I may have made in completing the initial or any subsequent paperwork.

Chiropractic, as well as many other types of health care, is associated with potential risks in the delivery of treatment. Therefore it is necessary to inform the patient of such risks prior to initiating care. While chiropractic treatment is remarkably safe, you need to be informed about the potential risk related to your care to allow you to be fully informed before consenting to treatment. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise or guarantee a cure for any symptom, condition or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal and if the results are not acceptable, we will refer you to another provider who we feel can further assist you.

Specific Risk Possibilities Associated with Chiropractic Care:

Soreness – Chiropractic adjustments and related physical therapy procedures are sometimes accompanied by post treatment soreness. This is a normal and acceptable accompanying response to chiropractic care and physical therapies. While it is not generally dangerous, please inform the doctor if you experience soreness or discomfort.

Rib Injury – Manual adjustments to the thoracic spine, in rare cases, may cause rib injury or fracture. Precautions such as pre-adjustment x-rays are taken for cases considered at risk. Treatment is performed carefully to minimize such risk.

Stroke – Stroke is the most serious complication of chiropractic treatment. The most recent studies (Journal of Manipulative and Physiological Therapeutics February 2009) found no evidence of EXCESS risk of VBA stroke associated from chiropractic care compared to primary care.

Other Problems – There are occasionally other types of side effects associated with chiropractic care. While these are rare, they should be reported to your doctor promptly.

If you have any questions concerning this form or the above statements, please ask the doctor.

Having carefully read the above, I hereby give my informed consent to have chiropractic treatment administered.

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 signature

Date

Witness

Date

INSURANCE ASSIGNMENT AGREEMENT

We are excited that you have chosen chiropractic care! To assist and accommodate you, we will accept insurance assignment with the following stipulations:

HEALTH INSURANCE:

We will accept partial assignment on approved major medical and other insurance plans that will pay for chiropractic care. You must pay any deductibles and/or copays stipulated by your policy. Terms are available for the portion that the insurance company makes you responsible. You must sign this form to be eligible.

AUTO AND/OR WORK COMP:

We will accept full assignment for these types of insurance, which means you pay for the items not allowed by the insurance company. If you discontinue your treatment without completing the recommended care plan or obtaining consent from your doctor, your balance may become due and payable. You must agree to bring any insurance payments you receive to the office upon receipt.

We DO NOT accept 3rd party liability insurance assignment. You MUST use your PIP, Med-Pay, health insurance, or have an attorney.

If you follow these stipulations as outlined, we will carry your account until payment is received from the insurance company.

I HAVE READ AND DO UNDERSTAND THIS ASSIGNMENT AGREEMENT AND I AGREE TO COMPLY WITH ITS SPECIFICATIONS. IN THE EVENT I FAIL TO KEEP MY RECOMMENDED APPOINTMENTS, I UNDERSTAND THAT MY BALANCE COULD BECOME DUE AND PAYABLE. I UNDERSTAND THAT MY CHARGES ARE MY SOLE RESPONSIBILITY AND NOT THE RESPONSIBILITY OF THE INSURANCE OR ATTORNEY. I AGREE TO PAY ANY COLLECTION AND/OR ATTORNEY FEES NECESSARY.

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

Date

WITNESS

Date

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