Dodge Family Chiropractic 702 S. Denton Tap Rd Suite 150 Coppell, TX dodgefamilychiropractic.com
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- Harold Cannon
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1 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 s Name: Father s Name: Home Phone: Home Phone: Work Phone: Work Phone: Parent s Marital Status: Married Single Divorced Widowed List Ages of Other Children in Family: Predominant language used at home: Consent to Treat Being the parent or legal guardian of this child, I herby authorize this office and its doctors to examine and administer care to my son/daughter, as the examining/treating doctor deems necessary. I understand and agree that I am personally responsible for payment of all fees charged by this office for such care. Parent s Name: Signature: Date: Witnessed by: Payment Information Please read and sign our Financial Agreement.
2 Pregnancy History Today s Date: Child s Name: Sex: M / F DOB: Age: Mother s Name: Number of Children: Term of Pregnancy: weeks DURING YOUR PREGNANCY DID YOU HAVE ANY OF THE FOLLOWING Falls Motor Vehicle Accidents Near-miss MVAs High Blood Pressure Diabetes Anemia Morning sickness Indigestion Y / N Seizures Swollen ankles Thyroid problems Back pain Abnormal bleeding Were you hospitalized? Any other illnesses DURING YOUR PRENANCY, DID YOU USE ANY OF THE FOLLOWING Tobacco Alcohol Non-prescribed drugs Prescription medication Over the counter meds
3 Birth History How long was labor from the first regular contractions to the birth? How long was the pushing stage of labor? Hospital birth Home birth Midwife assisted Doula present Vaginal Delivery Planned C-section Emergency C-section Induced (pitocin) Forceps delivery Vacuum extraction Anesthesia administered Fetal distress Meconium staining Head presentation Face presentation Breech presentation Baby s Condition Immediately After Birth Apgar Scores: At 1 minute /10 At 5 minutes /10 Baby s Crying Baby Cried Immediately After Birth Cried Strongly Weak Cry Did Not Cry for min Baby s Color Pink all over Blue Face Blue Hands/feet Baby s Activity Arms and legs actively moving Floppy baby Intensive Care Was required Days in Neonatal Intensive Care Unit Medication given at birth? Vaccines administered Birth Weight lbs/kgs Birth length in/cm Baby home on day
4 The following questions are designed to help the doctor provide the best possible spinal care for your child How many hours does your baby sleep between feeds? During Day At night Y / N Does your baby go to sleep easily? Y / N Does baby have a preferred sleeping position? Y / N Does baby cry if you change this sleeping position? Y / N Does baby have any feeding difficulties? Y / N Does baby have any feeding difficulties? Y / N Is baby being breastfed? If no, for how long was baby breastfed? Y / N Does baby have a one sided breast-feeding preference? Preferred side Left / Right Y / N Is baby formula fed? Which formula or other milk source? Y / N Does baby frequently spit-up after feeding? Y / N Does your baby cry a lot? For how many hours each day? Y / N Does baby pass a lot of intestinal gas? Y / N Does baby have a preferred head position? Y / N Does baby frequently arch his/her head and neck backwards? Y / N Does baby cry or become irritable during a diaper change? Y / N Has baby ever had a fever? Y / N Has baby had any falls? Y / N Has baby been in a car accident or near miss? Y / N Has baby had any other trauma? Y / N Has your baby been vaccinated? Y / N Do you have any other concerns you wish to discuss?
5 INFORMED CONSENT TO EXAMINATION AND CHIROPRACTIC TREATMENT I, understand that this office does not file my insurance and that any fees incurred for treatments are charged directly to me and are my sole responsibility. I herby authorize the Doctor to perform upon e examination and diagnostic procedures arising from any current or presently unforeseen conditions, which the Doctor considers necessary or advisable in the course of my health care. The Doctor will be treating his/her patients through any or all of the following: the adjustment of the spine through both low and high force techniques, nutritional counseling, and exercise. The Doctor will utilize various Chiropractic techniques in order to best serve each individual patient. These techniques may include adjustment of the cranial bones, the vertebral column, the pelvis, and the upper and/or lower extremities. The techniques focus on maintaining healthy spinal alignment and motion thereby influencing nervous system function. The Doctor will not directly treat any specific medical conditions. The material risks inherent in the Chiropractic adjustment: - As with any health care procedure, there are certain complications, which may arise during a chiropractic adjustment. Those complications include: fractures, disc injuries, dislocations, muscle strain, Horner s syndrome, diaphragmatic paralysis, cervical myelopathy, and costovertebral strains and separations. 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 The probability of those risks occurring - Fractures are rare occurrences and generally result from some underlying weakness of the bone, which we check for during the taking of your history, examinations and possible x-rays. Stroke has been the subject of tremendous disagreement within and without the profession with one prominent authority saying that there is at most a one-in-a-million chance of such an outcome. Since even that risk should be avoided if possible, we employ tests in our examination, which are designed to identify if you may be susceptible to that kind of injury. The other complications are also generally described as rare. It is important that you understand other treatment options outside of Chiropractic care are available to you. Other treatment options for you condition may include: - Self-administered, over-the-counter analgesics and rest. - Medical care with prescription drugs - Hospitalization - Surgery
6 The material risks inherent in such options and the probability of such risks include: - Overuse of over-the-counter medications produces undesirable side effects. Premature return to work and household chores may aggravate the condition and extend the recovery time. The probability of such complications occurring is dependent upon the patient s general health, severity of the patient s discomfort his/her pain tolerance, and self-discipline in not abusing the medication. Professional literature describes highly undesirable effects from long term use of over-the-counter medications - Prescription medications can produce undesirable side effects and patient dependence. The risk of such complications arising is dependant upon the patient s general health, severity of the patient s illness, Such medications generally entail very significant risks, some with rather high probabilities - Hospitalization in conjunction with other care bears the additional risk of exposure to communicable disease, iatrogenic (doctor induce) mishap, and expense. The probability of iatrogenic mishap is remote, expense is certain, exposure to communicable disease is likely with adverse result from such exposure dependent upon unknown variables. - The risks inherent in surgery include adverse reaction to anesthesia, iatrogenic (doctor induced) mishap all those of hospitalization, and an extended convalescent period. The probability of those risks occurring varies according to many factors. The risks and dangers attendant to remaining untreated - Remaining untreated allows the formation of adhesions and reduces mobility, which sets up a pain reaction further reducing mobility. Over time this process may complicate treatment, making it more difficult and less effective the longer it is postponed. The probability that non-treatment will complicate a later rehabilitation is very high. I, UNDERSTAND THE RISKS INVOLVED IN CHIROPRACTIC TREATMENT, THE OTHER OPTIONS AVAILABLE AND THEIR RISKS, AND THE RISKS OF REMAINING UNTREATED. BY SIGING BELOW I STATE THAT I HAVE WEIGHTD THE RISKS INVOLVED IN UNDERGOING TREATMENT AND HAVE MYSELF DECIDED THAT IT IS IN MY BEST INTEREST (OR SAID MINOR S INTEREST) TO UNDERGO THE TREATMENT RECOMMENDED. HAVIGN BEEN INFORMED OF THE RISKS, I HEREBY GIVE MY CONSENT APPROPRIATE THROUGH THE USE OF MANIPULATION OF MY SPINE AND EXTREMITIES, NUTRITIONAL CHANGES, AND RECOMMENDED EXERCISES AND ACKNOWLEDGE THAT NO GUARANTEE OR ASSURANCE AS TO THE RESULTS THAT MAY BE OB TAINED FROM THIS TREATMENT HAS BEEN GIVEN TO ME. Patient Signature (18 and over): Date: Patient Printed Name: Parent or Guardian Signature (for minors):
7 FINANCIAL POLICY Our first concern in this office is to provide you, the patient with excellent chiropractic care and wellness education. 1. Payment for the Initial New Patient Visit with our doctors is required at the time of your first visit to our office. All other payments, including adjustments, nutritional evaluation, allergy clearing, and vitamin/supplements are due at the time that the services are performed. For your convenience we accept cash, checks, MasterCard, Visa, Discover and American Express Credit cards. 2. Because we run a cash practice, we DO NOT file an insurance claims including Medicare. We are currently not providers for Medicare, which means you WILL NOT and CANNOT be reimbursed by Medicare for your visits to our office. Upon request we will print a statement that will provide you and your private insurance carrier with the information necessary to make a claim. If you wish to file a claim you are responsible for contacting your insurance carrier and submitting your claim. Please note that this does not guarantee payment for any part of services rendered. It has been our experience that insurance companies will often deny reimbursement for procedures. It is not uncommon for some insurance companies to deny a claim either at the onset of the patient s acute care or when a patient seeks reimbursement for wellness care. Most insurance companies do not understand wellness care and true holistic prevention. They are allopathic in nature and reimburse accordingly. Please, take the opportunity to educate your insurance providers as to the value of a wellness lifestyle. 3. Missed Appointment Policy Please be sure to give us 24 hours notice if you need to cancel or reschedule your appointment. If patient No-Shows (does NOT call or leave a message) or cancels within the 24 hour period a fee in the amount of the visit that was scheduled will be charged. 4. Automobile Accident Policy Our office will be happy to file your Personal Injury case if the insurance company that will be handling your case has approved you. After treatment is finished you then become responsible for your balance whether paid with the insurance check received for treatment or from your own personal account. If the insurance company did not cover all of your treatment you become responsible for the remaining balance. All questions regarding other financial matters should be addressed with the office manager or Doctor if necessary. We want you to be comfortable dealing with these matters, and we believe open communication will enhance the positive outcome we all desire. Patient Signature: Date:
8 AUTHORIZATION TO LEAVE MESSAGES AND CONVEY INFORMATION Patient Name: It is sometimes necessary for representatives of Dodge Family Chiropractic to contact patients for various notification purposes. The purposes of these communications can range from reminders of appointments, to notify patients that supplements or products they requested are ready for pickup or to ask a patient to call Dodge Family Chiropractic regarding an issue or concern. At no time will a representative of Dodge Family Chiropractic discuss your medical circumstances or condition without your consent. The purpose of this consent is to leave messages with members of your household, on your answering machine or voic service or through with your consent below. You have the right to revoke this consent, in writing, effective the day following your notification I authorize Dodge Family Chiropractic to LEAVE MESSAGES ON MY ANSWERING MACHINE AND/OR VOIC USING THE CONTACT NUMBERS I HAVE PROVIDED. I authorize Dodge Family Chiropractic to LEAVE MESSAGES WITH HOUSHOLD MEMBERS I authorize Dodge Family Chiropractic to contact me at the following address: Contact Patient Signature: Date:
Insurance. Patient Family Information. Patient Condition
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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:
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
Terms of Acceptance:
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PATIENT ENTRANCE FORM
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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
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
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:
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
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
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Pediatric Health Story Form
Pediatric Health Story Form Child s Personal Information Name Age Date of Birth Gender: M F Home Address City State Zip Names and Ages of Siblings Parent A Name Home phone ( ) Cell phone ( ) Employer E-mail
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
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
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
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
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
Patient Intake Form Please Write Legibly
Chiropractic Wellness Center Date: Patient Intake Form Please Write Legibly Patient Legal Name: Male Female Preferred Name: Date of Birth: Age: Home Address: Apt#: City: State: Zip: Home Phone: Cell Phone:
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
State: Zip Code: Home Phone#: Child resides with: Both Parents Mother Father Other Parent s address:
Child s Name: Address: Today s Date: City: State: Zip Code: Home Phone#: Date of Birth: Age: Gender/Sex: Male Female Child resides with: Both Parents Mother Father Other Parent s email address: Mother
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
New Patient Information
New Patient Information First Name: Last Name: M.I.: Address: City: State: Zip Code: Mobile Phone: Home Phone: Email: Preferred method of communication: Mobile Phone Home Phone Email Date of Birth: Age:
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
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY Tel # PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY 10016 Tel # 212-481-0064 PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A Last Name First Name Age Date Of Birth Sex Marital Status
WELCOME TO FALLS CHIROPRACTIC AND INJURY!
WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /
Child s Information (Please print) Name Birth Date Age Home Address City State Zip Code
The following questions are asked so that we can best understand your child. Please fill out this questionnaire before the child is evaluated. Please read the questions carefully and answer them as fully
LIST YOUR HEALTH CONCERNS BELOW
T 1 2 3 ROOTS CHIROPRACTIC HEALTH PROFILE In Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Work Email Address Date of Birth / / Occupation Employer's Name Single / Married / Divorced