Hamilton Back Clinic
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- Carmella Pierce
- 5 years ago
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1 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 Phone: Name of Extended Health Insurance Co: Please indicate what your coverage includes: Chiropractic Acupuncture Physiotherapy Foot Orthotics Don t Know Who may we thank for referring you? Reason for Visit: When did this occur: Due to auto/work injury?: How would you describe the pain?: Is pain constant? Does pain travel? Where? What makes it worse? Sitting Walking Bending Other What makes it better? Ice Heat Rest Exercise Meds What medications are you currently taking?: Any previous trauma (fall, accident) Any previous surgeries? _ Any food / drug allergies? Have you seen any other doctors for this condition? _
2 Medical History Please check off the box if you have a family history of the following: Cancer Type: Heart Disease Diabetes At the best of my knowledge I am pregnant Lung Disease High Cholesterol / Blood Pressure Thyroid Disease At the best of my knowledge I am not pregnant * Should you become pregnant please advise the doctor at your next visit. Please check off the box if you have had or currently suffer from the following: AIDS/ HIV ANAEMIA ARTHRITIS ASTHMA ANOREXIA APPENDICITIS BLEEDING DISORDERS BREAST LUMP BRONCHITIS BOWEL DISEASE BULIMIA CANCER EARACHES DIABETES EMPHYSEMA EPILEPSY FRACTURES GLAUCOMA GOUT HEADACHES HEART DISEASE HEPATITIS HERNIA HIGH CHOLESTEROL/ BLOOD PRESSURE KIDNEY DISEASE LIVER DISEASE LOW BACK PAIN LUNG DISEASE MUMPS MONONUCLEOSIS MULTIPLE SCLEROSIS MUSCULAR DISEASE MENTAL DISEASE MIGRAINES NECK PAIN OSTEOPOROSIS PNEUMONIA POLIO PROSTHESIS RHEUMATIC FEVER PACEMAKER SCARLET FEVER SORE MUSCLES STROKE STD S SKIN DISORDERS TENDONITIS THYROID DISEASE TUBERCULOSIS TUMOURS ULCERS OTHER The information I have given in both the patient history and medical history are correct to the best of my knowledge. Signature Date
3 PAYMENT SCHEDULE Chiropractic/Acupuncture Initial Visit (Standard) $75 Standard Visit $48 Standard Visit with Medical Acupuncture (Standard) $48 Laser Therapy $48 Physiotherapy Initial Visit $85 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 a missed appointment.
4 Informed Consent to Chiropractic/ Physiotherapy 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 stage 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. 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 of 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/physiotherapist. I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss with my chiropractor/physiotherapist the nature and purpose of chiropractic/physiotherapy 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/physiotherapy treatment recommended to me by my chiropractor/physiotherapist including any recommended spinal adjustments. I intend this consent to apply to all my present and future chiropractic/physiotherapy care. Dated this day of, 20 Patient Signature (Legal Guardian) Witness of Signature
5 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 procedure. 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 poses slight risks from treatment, including but not limited to temporary soreness, bruising, blistering, nausea, fainting, bleeding, lung injury, infection and shock. I don t not expect acupuncturists to be able to anticipate and explain all risks and complications and I wish to rely on the acupuncturist to exercise judgement 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 of Signature (Please Print) (Please Print)
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
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
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Address: Yes! I would like to receive your Monday Morning Health Tips.
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AHI - New Patient Information
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PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
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:
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
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
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.
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
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
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
Chiropractic Case History/Patient Information
Family Chiropractic and Wellness. 1 Chiropractic Case History/Patient Information Date: Patient # Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Birth
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
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
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