Informed Consent to Chiropractic Treatment
|
|
|
- Domenic Maxwell
- 6 years ago
- Views:
Transcription
1
2
3 1600 Rymal Rd East Hamilton ON L8W 3P1 Ph: Fax: Informed Consent to Chiropractic Treatment There are risks and possible risks with manual therapy techniques used by doctors of chiropractic. In particular you should note: A) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures. B) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in early stages of a stroke. In essence, there is a stroke in progress. However you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote. C) There are rare reported cases of disc injuries following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment. D) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy offered by some doctors of chiropractic. I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this consent. I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended Spinal adjustments. I intend this consent to apply to all my present and future chiropractic care. Dated this day of, 20 Patient signature (Legal Guardian) Witness of signature Name (Please print) Name (Please print)
4 1600 Rymal Rd East Hamilton Ontario L8W 3P1 Ph: Fax: Informed Consent for Acupuncture I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture if necessary including needling, moxabustion, cupping, guasha, laser, electro acupuncture and other techniques within the scope of practice of acupuncturists. These procedures may be performed by the acupuncturist or another duly authorized person in the clinic. I have had the opportunity to discuss with the acupuncturist and /or with other office or clinic personnel the nature and purpose of acupuncture care and other procedures. I understand that results are not guaranteed. I have been advised that all insertion needles are pre-sterilized and disposable. I further understand and am informed that, as with all health care, the practice of acupuncture posses slight risks from treatment, including but not limited to temporary soreness, bruising, blistering, nausea, fainting, bleeding, lung injury, infection and shock. I do not expect acupuncturists to be able to anticipate and explain all risks and complications and I wish to rely on the acupuncturist to exercise judgment during the course of the procedures which the acupuncturist feels at the time, based upon facts then known, are in my best interest. I have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above named procedure(s). I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Dated this day of,20 Patient Signature Witness Name: (please print) Name: (please print)
5 Hamilton Back Clinic p.c Rymal Road East, Hamilton, ON L8J 2R5 Payment Schedule Chiropractic / Acupuncture Initial Visit (Standard) $75 Standard Visit (Standard) $45 Laser Therapy $45 Physiotherapy Initial Visit $82 Follow Up Visit $62 ** I understand payment is due on the same day that I have been treated. Patient Signature: / Date: Missed Appointments If you must cancel an appointment, we require that you notify us 6 hours prior to your scheduled appointment. There will be a $15.00 fee for missed appointment. Revised September 19, 2011
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
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:
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:
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 #
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
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
Universal Health & Rehabilitation, PC
28 Finch Avenue West, Suite 212 Tel: (416) 628-1336 Pain.Drs@gmail.com www.pain-drs.com Your Multidisciplinary Healthcare Solution Thank you for choosing our office! To ensure your visit with us is a pleasant
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)
Information Release Form
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
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
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
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
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
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:
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
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
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
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
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
Patient Health Record
Name: Date: AHC #: Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email for appointment reminders and information regarding your
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
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:
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:
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
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
WELCOME. Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally.
WELCOME Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally. Before your Visit: You should eat a light meal or snack
TEMPE COMMUNITY ACUPUNCTURE (480)
TEMPE COMMUNITY ACUPUNCTURE (480)269 0415 WWW.TEMPEACU.COM HEIDI@TEMPEACU.COM Welcome to Tempe Community Acupuncture! TCA is one of many community acupuncture clinics established in the country who are
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
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET ADDRESS: PROVINCE: HOME PHONE: (CHECK WHICH PREFERRED) WORK PHONE: EMAIL ADDRESS: NEW LEGISLATION REQUIRES THAT WE OBTAIN CONSENT PRIOR TO SENDING EMAILS TO
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
Chiropractic Patient Admittance Form
Chiropractic Patient Admittance Form PERSONAL INFORMATION Last Name: Given Name: Initial: Address: City/Province: Postal Code: Home Phone: Work Phone: Cell: E-mail Address: Date of Birth (D/MM/YYYY): Male
CONDITIONS OF SERVICES RENDERED
CONDITIONS OF SERVICES RENDERED FINANCIAL AGREEMENT: I agree, whether I sign as agent or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate
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:
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
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
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 #
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
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
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:
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
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:
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
(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
Spencer Jean, DO(MP) Osteopathic Manipulative Medicine, Inc.
Spencer Jean, DO(MP) Osteopathic Manipulative Medicine, Inc. Spencer Jean, DO(MP) Osteopathic Manipulative Medicine, Inc. Clinic Tel: 519.735.7555 Cell: 519.551-3463 Email: s.jean@manualosteopath.com
3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
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
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
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
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
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
Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:
Name Age Date Please list All your current health complaints, including the reason that brought you to our office: List any other doctors see for current problems and list treatment received and results:
Adult Health Questionnaire
Health for Life Chiropractic At Cloverdale Mall Unit #143-250 The East Mall Etobicoke, ON, M9B 3Y8 416-232-1822 416-232-0060 Dr. Chrystopher Sly B.Sc, D.C. Dr. Jesse Cracknell B.A., D.C. Adult Health Questionnaire
Rise Chiropractic 239 S. French Broad Ave Asheville, NC
Rise Chiropractic 239 S. French Broad Ave Asheville, NC 28801 828.989.8369 1 Name: of Birth: Age: Sex: M F Address: City/State: Zip: Phone: (H) (W) (C) SS# Email: Occupation: Employer: Marital Status:
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 &
CHIROPRACTIC NEW PATIENT HEALTH HISTORY
CHIROPRACTIC NEW PATIENT HEALTH HISTORY Name: Last: First: MI: Address: City: Province: Postal Code: E-mail address: Cell Phone: Home Phone: Age: Birth Date: Alberta Health #: Occupation: Employer: Marital
PATIENT INFORMATION. Address City State Zip. Home Phone Work Phone Cell Phone Is it okay to contact you at work? Yes No. SSN - - DOB Age
PATIENT INFORMATION Name Date Address City State Zip Home Phone Work Phone Cell Phone Is it okay to contact you at work? Yes No Carrier: E-mail @ SSN - - DOB Age Occupation: Employer: Marital Status: S
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
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
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
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
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
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
PEDIATRIC HISTORY FORM
PEDIATRIC HISTORY FORM Today s Date: MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code:
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
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:
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
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:
PERSONAL INJURY VERIFICATION
PERSONAL INJURY VERIFICATION Name Email Home Phone Cell Phone Address City Zip Code Birth Date Age Marital Status Employer Occupation Name of Spouse In case of emergency, please notify Phone MED-PAY Policy
Please complete this profile, the answers will help determine if Chiropractic can help your child. Child s Name: Parent 1 Name: Parent 2 Name:
Pediatric Patient Profile Dear Parent: Please complete this profile, the answers will help determine if Chiropractic can help your child. Personal Information Date: Child s Name: Parent 1 Name: Parent
Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other
Patient s Name Date: What is the reason for you visit today? Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone # (home)
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
INFORMED CONSENT TO TREAT Single Point Acupuncture, LLC
INFORMED CONSENT TO TREAT Single Point Acupuncture, LLC I hereby request and consent to the performance of acupuncture and other procedures within the scope of acupuncture practice, as well as energy work
!"#$%&'(")'$*)'&+"$,-./$
!!"#%&'(")'*)'&+",-./! 0-1&2345&'"6666666666666666666666 5&'"-78(.'966666666:66666666:6666666666,(.4'!&/"66666666666666666666666666;(1111."4466666666666666666666666666666666?('2666666666666666666666@'&'"66666666A(B?-1"666666666666666
Dynamic Balance Chiropractic Adult New Patient Questionnaire
1. Please fill in the following Patient Information: Dynamic Balance Chiropractic Adult New Patient Questionnaire Patient Name Date Male Female Age D.O.B. Address City Province Postal Code Home Phone Work/Cell
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
Welcome To Corporate Chiropractic Works!
Welcome To Corporate Chiropractic Works! When a person seeks the services of a chiropractor, it is important to fully understand the purpose and intent of that particular chiropractor and the chiropractic
Have you ever been in a vehicular collision? (Please list date(s) and severity):
Physical History: Have you had any impacts or falls that you feel may have injured your spine? Please explain: Broken Bones? Surgeries? Are you ac@ve in any par@cular sports? Do you exercise? DAILY / 2-3x
PEDIATRIC PRE-EXAM INFORMATION
PEDIATRIC PRE-EXAM INFORMATION Name: Date of Birth dd /mm /YY Sex: M F Age Address Postal Code Mother s Name Home Phone: Occupation : Work Phone: Father s name Home Phone: Occupation: Work Phone: Siblings
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
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
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
The Wellness Lounge Staff
Chiropractic Massage Acupuncture Nutrition Yoga Treatment Welcome, We would like to take a moment to welcome you to the wellness lounge. Whether you are here for a one-time visit, or are looking for a
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
Chiropractic for pediatric development and adult health
Raleigh Specific Chiropractic Chiropractic for pediatric development and adult health 7721 Six Forks Rd. Suite 138 Raleigh, NC 27615 (919) 846-7004 Items to bring to your first visit: All new patient paperwork
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
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
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
Rosewood Family Healing Center. New Patient Intake Form
Rosewood Family Healing Center New Patient Intake Form Print Name Date Email Date of Birth Age Phone Number Marital Status- M D S W Occupation # of hours/day at a desk Repetitive movements Who may we thank
ROB AYOUP NATUROPATHIC DOCTOR. Pediatric Medical Intake. Name Date. Phone Home May messages be Work left relating to your Other visits?
ROB AYOUP NATUROPATHIC DOCTOR Pediatric Medical Intake Name Date Date of Birth Sex M F Address Phone Home May messages be Work left relating to your Other visits? Y N Guardian Name Emergency Contact: Name
Dodge Family Chiropractic 702 S. Denton Tap Rd Suite 150 Coppell, TX dodgefamilychiropractic.com
New Patient Information Date: Child s Name: Nickname: Reason for Visit: Sex: M / F Date of Birth: Age: Child s SSN: Child s Home Phone Number: Child s Home Address: Referred By: Family Information Mother
15901 Central Commerce Drive, Suite 102 Pflugerville, Texas (512)
15901 Central Commerce Drive, Suite 102 Pflugerville, Texas 78660 (512) 494-4050 PATIENT INFORMATION Full Name (Print): Sex: M / F Date of Birth: (MM/DD/YY) / / Age: Street Address: City: State: Zip Code:
Kinetic Performance Center Glenmore Trail SW Calgary, Alberta T2V 4R6. Patient Information. Date of Birth (M/D/Y) Age: Sex: M F
Kinetic Performance Center 408-1011 Glenmore Trail SW Calgary, Alberta T2V 4R6 Phone: (587)955-9910 Fax: (587)955-9911 Patient Information Date: Last name: First Name: Middle Initial: Date of Birth (M/D/Y)
Patient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
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