Information Release Form
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- Ernest Benson
- 5 years ago
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5 Information Release Form Name: Date: Contact Preferences By signing below I give permission to Whole Health Chiropractic to leave messages regarding my appointments, nutrition, or other health information via the following methods unless otherwise specified (strike through any methods you wish to not receive). o Voice Message on Home Number / Cell Number / Business Number o Text Message to provided number o Message to provided address o Demand Force /text appointment reminders, newsletters, birthday wishes, etc. o Contact settings can be changed by following the instructions in an or text. Sign: Date: Digital Contact Release I understand that Whole Health Chiropractic seeks to be available for questions and further clarification that may be required through , texting, Facebook messages, or other digital outlets. I also understand that many of these forms may not be compliant with HIPAA (health information portability and accountability act) privacy standards for medical information. By signing I agree to allow Whole Health Chiropractic staff and doctors to discuss my health information with me via these non-secure forms. Nothing will be intentionally made public. Sign: Date: *By refusing signature, you are declining contact through these forms and all health information questions must be addressed by appointment or phone call. Testimonial Release Whole Health Chiropractic enjoys using testimonials to aid in patient awareness and education. I understand that by becoming a patient, my story may be told in written or oral form including online media. I understand that I have the right to determine the level of information revealed that connects me to the testimony personally including my name, initials, location, etc. I am aware that I can request the removal of my identifying information at any time. By signing below I give Whole Health Chiropractic the authority to use my: (Please select all that apply) o My initials o My name o Nothing (pseudonym) o Picture (if provided) Sign: Date:
6 Informed Consent to Chiropractic and Associated Care SERVICES Chiropractic & Manual Therapy: Chiropractic treatment will involve the doctor using their hands or an instrument to move your joints in order to impact the nervous system, which regulates the entire body. This may or may not result in a harmless pop sound, depending on the various techniques used. Manual therapies, such as myofascial reconfiguration and trigger point release, will involve the use of hands or tools to break up adhesions and impact the nervous system. Risks: The risks of Chiropractic and manual therapies include mild skin irritation, soreness or bruising. Extremely rare risks can include fracture, strain, sprain, stroke, or possible injury to intervertebral discs, nerves, the spinal cord or arteries in the neck. These risks are diminished by performing a thorough history, risk assessment, and examination. Acupuncture & Meridian Therapy: Acupuncture involves the use of needles to stimulate points on the body known to produce certain effects. Meridian therapy is the study of the energy systems in the body as it pertains to Traditional Chinese and other Eastern medicine practices, which includes acupressure, auriculotherapy, and some use of traditional herbal principles. Risks: The risks of Acupuncture therapy include bruising, numbness or tingling near needle sites for a few days, dizziness or fainting. Rare risks include organ puncture or infection. These risks are diminished by using sterile, disposable needles and practicing in a clean and safe environment. Functional Nutrition & Supplementation: Nutritional evaluation may include history, signs and symptoms analysis, laboratory testing (serum, skin, hair, urine, stool, saliva, etc), muscle testing, and bio-resonance testing. Recommendations may include lifestyle modification, dietary changes, and supplement suggestions. Risks: The risks of dietary and certain supplemental care may result in diarrhea, constipation, nausea, gas, headache, rashes or allergic response, toxicities, and deficiencies. These are diminished by taking ownership of the foods eaten and supplements taken, following general recommendations, and informing my medical and other doctors of any nutritional supplements or dietary changes. A full history, including medications, family and social history, is taken. Bio-resonance Testing: Bio-resonance testing is a form of bio-feedback that allows deeper analysis of the human body. It is not licensed by the FDA to diagnose or treat any condition and is not employed by most practitioners in this way. All decisions are ultimately made based on clinical and laboratory information regarding therapies or nutritional recommendations. Alternatives: Alternatives to Chiropractic and these associated methods include medical care (including medications and/or surgical procedures), massage therapy, physical therapy, over-the-counter medication, and other self-care. Risks of Non-Treatment: Delay of treatment may allow for progression of the current condition or reduction in healing with greater likelihood of formation of chronic pain or lifestyle limitations. CONSENT TO TREATMENT I hereby desire and request care via the methods above from Whole Health Chiropractic for myself or the patient, named below, for whom I am legally responsible. I have been informed of the risks, benefits and alternatives to Chiropractic, manual therapy, acupuncture, nutritional and herbal modification, and biofeedback testing. I am aware it is my sole responsibility to inform my physician to the best of my knowledge any health history or risk information so that my care plan may be adjusted accordingly. I also accept responsibility for seeking appropriate care for any conditions that arise before or after beginning care, including but not limited to pregnancy, diabetes, and any communicable diseases. I understand that my doctor at Whole Health Chiropractic cannot make any promises or guarantees regarding a cure or improvement of my condition. I understand they will share their professional opinion regarding potential results from Chiropractic care and will discuss treatment options with me, but it is my responsibility to remain informed and in charge of the direction of my care. I have been given the opportunity to ask pertinent questions regarding the above information. I understand that I am responsible for payment at time of service. My signature signifies that I have read this document and understand its purpose. I release Whole Health Chiropractic and its employed or affiliated practitioners from any liability. Patient Name (print): Legal Guardian (required to sign if patient under 18): Sign: Date: Witness: Date:
Informed Consent to Chiropractic Treatment
1600 Rymal Rd East Hamilton ON L8W 3P1 Ph: 905-692-4222 Fax: 905-692-0222 E-mail: info@hamiltonbackclinic.com Informed Consent to Chiropractic Treatment There are risks and possible risks with manual therapy
th Street Urbandale, IA YOST
YfC 3993 100th Street Urbandale, IA 50322 515.278.YOST www.yostfamilychiropractic.com Demographics: Language (Primary) Race: Unspecified American Indian or Alaska Native Black or African American Other
Patient Name: Male or Female DOB: Patient Address: City/State/Zip: Patient Phone Number: Primary Policy holder: Relationship: DOB:
Fax to: 972-393-4200 Email to: denise@points4health.com Points of Health & Herbal Medicine Denise Edmiston, L.Ac., LCSW 413 W. Bethel Rd., Suite 202 Coppell, Texas 75019 P-(972)506-8113 F(972)393-4200
Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212
Initial Intake Form: Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212 ( 3 0 3 ) 3 5 1-1 2 2 8 Name: Phone: Address: City: State: Zip: E-mail: Would you like to be added to our E-Mail newsletter
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name
General Information: (Circle One) (Circle One) Primary Insured's Information Skip if you are primary
General Information: First Name: Middle Initial: Last Name: Suffix: Called Name: Street Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: Marital Status:
SOUTHSIDE COMMUNITY ACUPUNCTURE, LLC. Financial Policies
Disclosure of Information - Please Read the Following Carefully How to Prepare for Your First Visit : Plan on showing up a 15 minutes early to your first appointment and please wear, or bring with you
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
Acknowledgment of Clinic Terms
Acknowledgment of Clinic Terms Our GOAL The goal of CHIRO-FIT, Inc. is to detect and correct subluxations of the spine and body. We do not focus on the treatment of pain and disease, instead aim to help
Patient Information Form
Patient Information Name: First Middle Last Address: City: State: Zip: Telephone: Home Cell Work Date of Birth: Social Security Number: (SSN is only needed if getting super-bills for potential insurance
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
Terms of Acceptance:
Terms of Acceptance: When a patient seeks chiropractic health care and we accept them for such care, it is essential for us both to be working towards the same objective. Chiropractic has only one goal:
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
Thrive Family Chiropractic
Thrive Family Chiropractic Dr. Kaitlin Parker, DC 1121 S. Bowman, Suite C-3 Little Rock, AR 72211 501.712.1022 Pediatric Vitality Questionnaire Name: Date: Birth Date: Gender: Male Female Parent s phone
Hamilton Back Clinic
Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer
Kimberly Anne Hoffman, L.Ac. (HIPAA) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME
Kimberly Anne Hoffman, L.Ac. (HIPAA) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME BIRTHDATE EMAIL PHONE I understand that as part of my
PEDIATRIC INTAKE. Child s Name: Date: Name of Parent(s)/Legal Guardians: Relationship to child: Address: City: State: Zip Code:
PEDIATRIC INTAKE I appreciate your willingness to fill out this form as completely as possible. It is invaluable information for developing a treatment plan tailored to your child s individual needs. General
Daniel Lander, ND, FABNO
1255 Sheppard Avenue East Toronto, ON M2K 1E2 416.498.1255 x 280 The Integrated Healthcare Centre at The Canadian College of Naturopathic Medicine Informed Consent & Request for Naturopathic Medicine Practitioner
Patient Information (please print clearly) Name: Date of Birth: mm/dd/yyyy / / Age: (to receive appointment reminders)
YOUR HEALTH Wellness Centre 1158 Winston Churchill Blvd Oakville, ON L6J 0A3 Chiropractic New Patient Form Patient Information (please print clearly) Name: Date of Birth: mm/dd/yyyy / / Age: Address: City:
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
Health and History Assessment ACCOUNT #: HIPPA: CTT:
ACTION Chiropractor LLC Health and History Assessment ACCOUNT #: HIPPA: CTT: NAME: SEX: M/ F BIRTHDATE: / / ADDRESS: CITY: STATE: Zip: PHONE # s: HOME: ( ) WORK: ( ) CELL: ( ) HEIGHT: WEIGHT: MARITAL STATUS:
Insurance. Patient Family Information. Patient Condition
Welcome to Amarillo Family Wellness Group In order to serve you best we would like to know more about you and your health history. Please print clearly and fill this out completely prior to your appointment
GENERAL INFORMATION HEALTH & LIFESTYLE PROFILE
GENERAL INFORMATION Name Today s Date // Address City/State/Zip Mobile Phone # _ Other Phone # Your Birthdate Occupation Employer Relationship: Single Married Partner Widow Children: Yes No How did you
Cascadia Chiropractic Centre
Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital
Dr. Mark VanOtterloo DAOM - Licensed Acupuncturist
Please keep your healthcare practitioner aware of any changes to your personal information as soon as possible THANK YOU! Patient Info Printed Name: Address: DOB: / / Gender: Marital Status: S M D W Employer:
MacKay Chiropractic, LTD., 7450 W. Cheyenne Ave. #114 Las Vegas, NV (702)
Personal History Date Patient # Name: Address: City: State: Postal Code: Birth date: Age: Sex: M F Home Phone: _ Cell Phone: Social Security #: Type of Work Email (for appt/e-news letter): Business/Employer:
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
Child (0-17) New Patient Intake Form. Child s Health Summary
Child (0-17) New Patient Intake Form Child s Name Age Birth Date / / Soc. Sec. # - - Parent/Guardian Name: Address: City: State: Zip: Parent/Guardian Email: Parent/Guardian Phone: Whom may we thank for
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
7035 Beracasa Way, Suite 103 Boca Raton Florida, 33433 Phone# (561)674-1217 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name middle Address City State Zip Date of Birth Age Social Security
Carter Physiotherapy, PLLC Patient Contact Information
Carter Physiotherapy, PLLC Patient Contact Information Patient Name Today s Date Address City State Zip DOB Age Gender Marital Status Cell Phone Home Phone Email Employer Occupation Parent/Guardian/Spouse
Welcome to Manna Family Chiropractic!
Welcome to Manna Family Chiropractic! Today s date Who should we thank for referring you here? Is your visit today regarding you, or your whole family? Family Just Me Your name Date of Birth Street Address
Ages 6 to E. Lohman Ave Ste 22 Las Cruces, NM (575) Today's Date: Date of Birth: Phone Number with Area Code:
3961 E. Lohman Ave Ste 22 Las Cruces, NM 88011 (575) 652-3358 Ages 6 to 18 Today's Date: Name: Date of Birth: Sex: Male Female Mailing Address: Parent/Guardian Names & Phone Numbers: Phone Number with
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please print clearly) Last Name MI First Name Date of Birth Home Address Mailing Address if different Home Phone Work Phone Other/Cell Phone EHR Certification Patient Information
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
PATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Revelation Chiropractic Health Profile
Revelation Chiropractic Health Profile Name Date / Age Male / Female Address Apt City Zip Phone Numbers: Home Cell Circle best number to reach you at: Home Cell Date of Birth / / Occupation Email Address
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX
Liberty Chiropractic Clinic, -6154 Patient's Name Patient's Address City State Zip Code Age D.O.B. Single Married Divorced Widowed No. of children Occupation Employer Home Phone Work Phone Cell Phone Email
PATIENT INTAKE FORM MR#:
PATIENT INTAKE FORM MR#: Name: Date: Age: Sex: Date of Birth: Address: City: Zip: Home Phone: Work Phone: Cell Phone: E-Mail: Married Divorced Widowed Single Separated Occupation: Employer: Address: Primary
We Believe that you are Designed to be Extraordinary. (Office Use) Care Provider: Name: Date of birth (MM/DD/YY): Apt# City: Prov: PC:
(Office Use) Care Provider: Name: Date of birth (MM/DD/YY): Mailing address: Apt# City: Prov: PC: Phone: h) c) Email: Do we have your permission to send you our weekly health newsletter? Y N **You can
Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
Patient Information Name: First Last M.I. Date: Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Email: Phone: Cell/Home/Work (please circle one) How did you hear about us? Door hanger, Fargo
Client Intake Form - Therapeutic Massage
Client Intake Form - Therapeutic Massage Personal Information: Date: Name: Phone #: Address: City/State/Zip: Email: DOB: Occupation: Emergency Contact: Phone #: HOW DID YOU HEAR ABOUT US? The following
Cascadia Chiropractic Centre
Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card
RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
PATIENT ENTRANCE FORM
PATIENT ENTRANCE FORM Name _ Date Address City/ Province Postal Code Home Telephone Work Telephone Email Address Would like email reminders for appointments? Yes No Date of Birth (Day/Month/Year) Age Marital
PREVIOUS BIRTH EXPERIENCE
GENERAL INFORMATION Name Today s Date // Address City/State/Zip Mobile Phone # _ Other Phone # Your Birthdate Occupation Employer Relationship: Single Married Partner Widow Children: Yes No How did you
SMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC PHYSICAL THERAPY PATIENT INFORMATION CITY: STATE: ZIP CODE:
PHYSICAL THERAPY PATIENT INFORMATION DATE: NAME: DATE OF BIRTH: ADDRESS: CITY: STATE: ZIP CODE: *E-MAIL: HOW DID YOU HEAR ABOUT SMITH PHYSICAL THERAPY AND RUNNING ACADEMY? EMERGENCY CONTACT: REFERRING
LIST YOUR HEALTH CONCERNS BELOW
8209 Natures Way Unit 115 Lakewood Ranch, Florida 34202 (941) 877.1507 Name Date / / Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name
Authorizations and Acknowledgements. Treatment and Authorization: I authorize medical and health care treatment of myself
Terry Van Oort, MD BALANCED INTEGRATIVE HEALTH 302 SW Walnut St, Ankeny, IA 50023 (P) 515-207-0999 (F) 515-639-3803 drterry@balancedintegrativehealth.com Authorizations and Acknowledgements Treatment and
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
Describe the pain and it s location:
WELCOME TO ZIVKOVIC CHIROPRACTIC CENTER DATE: Please print clearly and fill in completely. ABOUT YOU: Patient Name:_ What do you prefer to be called:_ SS# Street Address City State Zip Date of Birth: Age:
Current Health Information
Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms
Natural Health Center
Natural Health Center 420 Yucca Lane - Turpin, OK 73950 Tel. No. (580) 778-3310 / Cell No. (620) 391-5520 / Fax No. (580) 778-3340 Today s Date / / Application for Treatment Name: Birthdate: SS# Address:
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
North Jersey Physical Therapy Medical History Questionnaire. Name: Date of Birth: Age: Occupation: Currently working?:
Today s Date: North Jersey Physical Therapy Medical History Questionnaire Name: Date of Birth: Age: Occupation: Currently working?: How did you hear about our practice: Referring Physician (full name &
Welcome To Our Office
Welcome To Our Office Mission Statement Our office is dedicated to educating and adjusting as many families as possible towards optimal health through natural chiropractic care. We believe the greatest
Address: Yes! I would like to receive your Monday Morning Health Tips.
Welcome to our Office! New Patient Intake Form Date Name Preferred Name Birthdate (D/M/Y) Age Sex F M Address Unit City Province Postal Code Home # Cell # May we contact you at work? Yes No Work # Extension
What is your occupation? Company Name Do you have extended healthcare benefits? Yes No Benefits are personal or from work
Welcome to our Office! New Patient Intake Form Date Name Preferred Name Birthdate (D/M/Y) Age Sex F M Address Unit City Province Postal Code Home # Cell # May we contact you at work? Yes No Work # Extension
Ea Medical Weight Loss Services Solutions for permanent weight loss PATIENT HISTORY. When did you first become overweight? (Your age then) or Year
PATIENT HISTORY Name: Age: Date: When did you first become overweight? (Your age then) or Year How did your weight gain start? Describe any circumstances: What do you think is the cause of your weight
SURNAME: FIRST NAME: Address: Who Is your GP and where do they practice? Friend: Please Name
PATIENT INTAKE FORM OFFICE USE ONLY: Intake Date: Practitioner: Dr. S. Venaille Dr. C. Lees Dr. J. Mokrzycki Informed consent: / Limited Flags: Notes: TITLE: SURNAME: FIRST NAME: BIRTHDATE: AGE: SEX: M
Back In Balance Chiropractic, LLC
Back In Balance Chiropractic, LLC Date Name What do you prefer to be called Address City State Zip Code Birth Date: / / Social Security Number: - - Height: Weight: E-mail Home Phone ( ) - Cell ( ) - Contact
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
Pro Active Physical Therapy & Sports Medicine
Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
1. Have you ever had or now have: 2. Have you ever had or now have:
1. Have you ever had or now have: 2. Have you ever had or now have: Yes No Please Check each item no blanks CARDIOVASCULAR Yes No Often Seldom 1. Chronic or frequent colds 1. Shortness of breath with normal
Dr Chu Acupuncture Clinic 1615 Maxwell Dr. Suite D. Hudson, WI Patient Notes
Dr Chu Acupuncture Clinic 1615 Maxwell Dr. Suite D. Hudson, WI 54016 Patient Notes Patient Gender F M DOB Name Address Phone Work: Home: Cell: Email Chief Complaint How long has it been: Secondary complaint
Dr. Brett Whitekettle
Dr. Brett Whitekettle For Office Use Only: Patient ID #: 200 Cape Fear Circle Suite 2 Sneads Ferry, NC 28460 T: (910) 327-0022 F: (910) 327-0337 office@whitekettlechiropractic.com Patient Information Phone
Client Intake Form Therapeutic Massage
Personal Information: Client Intake Form Therapeutic Massage Name Phone (Day) Phone (Eve) Address City/State/Zip email Date of Birth Occupation Emergency Contact Phone The following information will be
New Pediatric Patient Information
Arden Yingling, L.Ac., MAcOM (TX #AC01588) 9300 US 290, Austin TX 78736 512.640.9778 arden@songbirdacupuncture.com songbirdacupuncture.com New Pediatric Patient Information Child's Name Today s Date Birth
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
www.monctonnaturopathic.com 12 Fifth Street, Moncton, NB, E1E 3G9 Ph: 506-382-1329 Fax: 506-382-1828 Pediatric Intake Form (6-12 years) Name: Date: Age: Date of Birth: / / Gender (circle one): female or
NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
Child s Name Date Parent(s) Name Siblings Names(Ages) Address City Prov. Postal Code Home Phone( ) Bus Phone( ) Date of Birth Age Referred by
Please complete the following as completely as possible. If you need assistance, please ask the front desk staff and they will be glad to assist you. Child s Name Date Parent(s) Name Siblings Names(Ages)
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Pediatric Chiropractic Intake Form (Children under 13) State: Zip Code:
Sunset Hills Family Chiropractic Dr. Brittany Warren, DC Dr. Robyn Kuhn, DC Dr. Nathan Free, DC 4600 S. Lindbergh Blvd., Suite 3. Saint Louis, MO 63127 Phone: 314-729-0027 / Fax: 314-729-1015 Pediatric
Consent for Treatment Form
Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
INNOVA Medical and Rehab Dr. Farhad Babakhani. BSc, DC, FCCRS, RAc # Elgin Mills Road East Richmond Hill, ON L4S 0B2
INNOVA Medical and Rehab Dr. Farhad Babakhani. BSc, DC, FCCRS, RAc #111-1650 Elgin Mills Road East Richmond Hill, ON L4S 0B2 Tel: (905) 884-2121 Fax: (905) 884-8845 PATIENT INFORMATION: Name: Address:
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED Patient Information Name: DOB: / / Gender: M F Home Address: Home Phone: City, State, Zip: Work Phone: Email Address: Cell Phone: I do not want
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
An Hao Natural Health Care Clinic 2348 NW Lovejoy St. Portland, OR
Edythe Vickers, N.D., L.Ac. Loren Lubin (Resident) Rachel Eppinga, N.D., L.Ac. Heather Krebsbach, N.D., L.Ac. Angela Read, L.Ac. Patient Intake Form Page 1 An Hao Natural Health Care Clinic 2348 NW Lovejoy