New Patient Paperwork

Confidential Case History

Please complete this questionnaire. Your answers will help us determine if our care can help you. If we do not sincerely believe that your condition will respond satisfactorily, we will not accept your case but will work to refer you to the appropriate healthcare provider. If you need help with this form, please ask our staff.

Name

Address

City

State

Zip Code

Birth Date

S.S. #

Sex

Male Female

Cell Phone #

Work Phone #

Occupation

Employer

Name of Insurance

Name of Subscriber

Subscriber Date of Birth

Relationship to Subscriber

Whom may we thank for referring you?

If the above patient is a minor, please fill out the following information:

Person responsible for account

(Parent and/or Guardian)

Address (if different)

Birth Date

S.S. #

I hereby state the above information to my knowledge is accurate.

Signature

Date

Website Membership Enrollment

The information on our website will help you GET WELL and STAY WELL. Please provide the following details so we can establish you as a member of our website. By joining our website, you authorize us to send monthly healthcare related emails to you. We will never out-source your email address to any company. Naturally, you may opt-out at any time. Please review our complete privacy policy on our website.

Email Address

Patient Condition

Health Information:

Have you ever been to a chiropractor before?

Yes No

Reason for today's visit

When did your symptoms appear?

Have you ever been seen previously by someone for the same condition?

Yes No

If yes, who?

Current & Past Health History

Headaches

Cancer

Tension

Heart Attack

Dizziness

Neck Pain

Shortness of breath

Chest Pain

Fatigue

Broken or Fractured Bones

Memory Loss

Fever

Diabetes

Arthritis

Depression

Diarrhea

Ringing in Ears

Tumors

Fainting

Stroke

Numbness

Tingling

Do you have pain and/or difficulty performing any of the following activities?

Daily Routine

Lifting

Working

Driving

Sleeping

Recreation

Walking

Sitting

Standing

Add new row

Rate the severity of the pain on a scale of 1 to 10

How often do you have this pain?

List surgical operations and years

List any medications, Vitamins, and Natural Supplements you currently take

Have you been in an auto accident

None Past Year Past 5 Years Over 5 Years

Describe

Have you had any other personal injury or accidents

None Past Year Past 5 Years Over 5 Years

Describe

I have a specific problem and require help only with this problem.

After my specific problem has been relieved, I am interested in strategies to ensure it does not return.

After my specific problem has been resolved and I understand methods to ensure it does not return, I am interested in strategies to improve my general health.

Billing

Outstanding patient balances will be billed monthly. Should my account become delinquent, I agree to pay collection costs, attorney fees and court costs as permitted by law if such are incurred by my physician at Meier Chiropractic. We will pass along the charge of $20 for any returned checks. If your case is a Personal Injury Case or Workers Comp case and you decide to terminate care against the doctor's advice, the entire balance will immediately become due and payable.

Agreement

This is the entire financial agreement between Meier Chiropractic and the patient below. I have read this agreement, understand it and agree with its provisions.

Patient or Responsible Party

Date

Informed Consent for Chiropractic Treatment

I hereby request and consent to the performance of Chiropractic adjustments and any other procedures, including examination tests, diagnostic x-rays and adjustment necessary to treat or diagnose my condition. Furthermore, I consent to treatment by any chiropractor that may be working for, associated with or serving as backup for my regular chiropractor named below.

I understand that, as with any health care procedure, there are certain risks involved. Some of the risks or complications which may occur during a chiropractic adjustment include, but not limited to; fractures, disc injuries, muscle strains, and costovertebral strains and /or separations. In a small percentage of the population there have been injuries to the arteries in the neck resulting in or contributing to stroke. In some of these incidents the manipulative procedures were performed by untrained people such as massage therapists, beauticians, and even medical doctors not adequately trained in the science of chiropractic.

By signing below I state I have weighed the risk involved in undergoing treatment and have myself decided that it is in my interest to undergo the chiropractic treatment recommended. I hereby give consent to the treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any other future conditions for which I seek treatment.

Treating Doctor: Jeffrey Meier, D.C; Kimberly Meier, D.C; Donnie Smith, D.C; Tilene Figeroa, D.C, Danyell Cobb, D.C., Kaylee Zard, D.C.

Do Not Sign Until You Have Read The Above

Printed Name

Date

Signature

Date

Witness Signature

Date

HIPAA Individual Acknowledgement of Privacy Practices

We here at Meier Family Chiropractic take your care very serious and want what is best for you at all times. Under the Health Insurance Portability and Accountability Act (HIPAA), your health care provider may share your information face-to-face, over the phone, or in writing.
A health-care provider may share relevant information if:

You give you provider permission to share this information
OR
You are present and do not object to sharing the information

If you would like us to share information (i.e. appointment dates/times, current balances, etc.) please list the person's name and we will be happy to abide by this. I authorize Meier Family Chiropractic to release my healthcare information to the following:

1.)

*By signing this form, I am indicating that I have been provided a copy of Meier Chiropractic's Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I may obtain a current notice by contacting Meier Chiropractic. The doctors and staff of Meier Family Chiropractic will follow the above directions until notified in writing of a change.

Patient/Guardian/Authorized Signature

Date

*Appointment reminders and private health information will be communicated to you only in the manners in which you have given specific written authorization and you have the option to opt out of any of those methods at any time by notifying our office. Email and standard SMS/text messaging are not confidential methods of communication and may be insecure.

I give permission to contact me, relative to appointment reminders only, by the following methods:

Phone message at the following number

Number

Cell Phone Provider

Text messages at the following phone number

Number

(Exp: Verizon)

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