New Patient Paperwork

What body part is involved? (Please mark the table below)

In this section, check the ONE BOX which best describes how your problem started. Then answer the questions below the box you checked. Use as much space to the right as needed.

Have you had any of these treatments?

Please list below:

REVIEW OF SYSTEMS

Have you had any of these symptoms?

PAST MEDICAL HISTORY

Past Surgical History: What operations have you had and when?

FAMILY HISTORY:

Have any direct relatives had any of the following disorders? If so, which relative?

SOCIAL HISTORY:

PLEASE SIGN: The information on these this form is accurate to the best of my knowledge.

Pain Diagram and Pain Rating

INSTRUCTIONS: Please use the diagram below to indicate the symptoms you have experienced over the past 24 hours. Use the key to indicate the type of symptoms.

Stabbing = / / / / / /
Deep Ache = zzzzzz

DEMOGRAPHIC INFORMATION

Patient Financial Responsibility Contract

Please read, initial each blank and sign where indicated- this document describes your financial responsibilities.
This is a legally binding contract between Riker Chiropractic and you. The words, I me, my, you and your all refer to the patient. ,

Current insurance cards must be presented at our request. I agree to pay the remaining balance after my insurance has paid on my claim immediately upon receipt of a statement

I agree to give Riker Chiropractic Office my complete and accurate insurance information for primary and secondary insurance benefits including referral documents from other providers, if needed. I understand that if I fail to give complete and accurate information about my insurance benefits this may result in a denial of my claim or a delay in payment. I agree to pay Riker Chiropractic Office the balance on my account after my insurance claim has been processed.

I agree that if my insurance benefits require me to provide a referral and if the referral is not in place before my appointment, that I will pay in advance an estimate of charges for my office visit or reschedule my appointment.

I understand that there will be a $25.00 fee for all returned checks.

if I have a high deductible policy or do not currently have insurance benefits, l agree to pay and estimate of charges for my office visit in advance and understand that other charges may apply.

Riker Chiropractic Office will receive payments from my insurance company for covered services provided by my insurance benefits. I agree to pay co-payments and deductibles at the time of service. If co-payments are not made at the time of service, I understand that my appointment may be rescheduled.

I agree to pay any balance remaining on my account for any reason upon receipt of a statement and I understand that when requested, I must give Riker Chiropractic Office my current address and other contact information. I understand that if I fail to pay the balance on my account this may result in Riker Chiropractic Office pursuing any collection means possible.

If my account becomes delinquent, it may be forwarded to an outside collection agency without notice. If this happens, I will be responsible for all cost of collection, including but not limited to interest, rebilling fees, court cost, attorney fees, and collection agency cost.

If the reason for my appointment is related to a work injury or auto accident, l agree to give Riker Chiropractic Office the case number of policy number, the workman's compensation or insurance carriers name, address or other contact information at the time of my appointment so that Riker Chiropractic Office can bill workman's compensation or the auto insurance carrier for my visit. If I do not provide this information at the time of the visit

I agree to pay all charges for my visit.I have read and understand Riker Chiropractic Office financial policies and I accept responsibility for the payment of any fees associated with my care.

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.

ACKNOWLEDGMENT OF OUR NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received or have been give the opportunity to receive a copy of Glenmont Chiropractic Office, PLLC Notice of Privacy Practices. By signing below I am “only” giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices.

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 FORM

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. In anything is unclear, please ask questions before you sign.

The nature of the chiropractic adjustment
One treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis / Examination / Treatment
As a part of the analysis, examination, and treatment, you are consenting to the chiropractic procedures.

The material risks inherent in chiropractic treatment
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.
Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The availability and nature of other treatment options

Other treatment options for your condition may include:

• Self-administered, over-the-counter analgesics and rest
• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-kille
• Hospitalization
• Surgery

If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

The risks and dangers attendant to remaining untreated
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Symptoms may increase and over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW

the above explanation of the chiropractic adjustment and related treatment. I have discussed it with Dr. Riker and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment