AUTHORIZATION FOR CHIROPRACTIC TREATMENT
|
|
|
- Dwight Johnson
- 5 years ago
- Views:
Transcription
1 AUTHORIZATION FOR CHIROPRACTIC TREATMENT I, the undersigned, a patient in this office, hereby authorize Virginia Family Chiropractic to administer such treatments as is necessary, and to perform the following therapy and manipulation and such additional therapy or procedures as are considered therapeutically necessary on the basis of finding during the course of said treatment. I hereby certify that I have read and dully understand the above Authorization for Chiropractic treatment, the reason why the above named treatment is considered necessary, the benefits and risks the side effects of the treatment, which were explained to me by Virginia Family Chiropractic. I understand and am informed that, as in all health care, in the practice of chiropractic there are some risks to treatment, including but not limited, to muscle strains and sprains, fractures, dislocations, disc injuries, strokes. I do not expect the doctor to be able to anticipate or explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of the treatments which he feels at the time, based upon the facts then known is my best interest. My doctor has responded to all of my requests for information about proposed treatment. I have read, or have had read to me, the above consent. I have also had the opportunity to ask about its content. By signing below, I consent to treatment. I also certify that no guarantee of assurance has been made as to the results that may be obtained. Print Name Date Signature Witness or Nearest Relative
2 Health Care Authorization Form (HIPAA) ALEXANDRIA WOODBRIDGE FALLS CHURCH 5130 Duke St Suite 114 Alexandria, VA P: (703) F: (703) Jefferson Davis Hwy. Suite 301 Woodbridge, VA P: (703) F: (703) Leesburg Pike, Suite 207 Falls Church, VA P: (703) F: (703) MANASSAS 8420 Dorsey Circle Suite 101 F: (703) THE FOLLOWING AUTHORIZES VIRGINIA FAMILY CHIROPRACTIC & PM PLLC TO USE AND/OR DISCLOSE PROTECTED HEALTH CARE INFORMATION IN ACCORDANCE WITH THE FOLLOWING SPECIFIC AUTHORIZATION: I give permission to Virginia Family Chiropractic PM PLLC to use my name, phone numbers and clinical records to contact me with birthday cards, holiday related cards, health related messages, text messages, and information about treatment alternatives or other health related information. I give permission to Virginia Family Chiropractic PM PLLC to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protective health care information during the course of my treatment. Should I need to speak with a doctor or assistant in private, the doctor or assistant will provide a private room for these conversations BY APPOINTMENT ONLY. By signing the following, you are giving Virginia Family Chiropractic PM PLLC permission to use and disclose your protected health information in accordance with the directives listed above. Signature of Patient/or Guardian Date ACKNOWLEDGEMENT OF RECEIPT & NOTICE OF PRIVACY PRACTICES I understand and have been provided with a notice of information practices that provides me a more complete description of information uses and disclosures: I understand that I have the following rights and privileges: The right to review the notice prior to signing this consent. Printed Name of Patient/or Guardian The right to object to the use of my health care information for directory purpose. The right to request restrictions as to how my health care information may be used or disclosed in this office to carry out treatment, payment, or health care operations. Signature of Patient/or Guardian Date Printed Name of Patient/or Guardian
3 ALEXANDRIA WOODBRIDGE FALLS CHURCH MANASSAS 5130 Duke St Suite Jefferson Davis Hwy. Suite Leesburg Pike, Suite Dorsey Circle Suite 101 Alexandria, VA Woodbridge, VA Falls Church, VA P: (703) P: (703) P: (703) F: (703) F: (703) F: (703) F: (703) Patient Registration and History Questionnaire Name: Age: Date of Birth: Date: Last First MI Address: Social Security #: - - City, State, Zip: Marital Status: M S W D Home Phone: ( ) Work/Cell Phone: ( ) Employer: Occupation: How were you referred to this office? In case of an emergency, notify Relationship: Phone: ( ) Reason for Office Visit: Date condition started: Have you had this before? Injury related? 1. [ ] yes [ ] no [ ] yes [ ] no 2. [ ] yes [ ] no [ ] yes [ ] no 3. [ ] yes [ ] no [ ] yes [ ] no Pain severity: If 10 is the worst pain imaginable, and 0 is no pain, please indicate your pain over the last 2 weeks: Pain location: Pain location: Pain Location: RIGHT NOW: /10 RIGHT NOW: /10 RIGHT NOW: /10 At its WORST: /10 At its WORST: /10 At its WORST: /10 At its BEST: /10 At its BEST: /10 At its BEST: /10 What makes your pain BETTER? (Check all that apply): [ ] Nothing [ ] Ice [ ] Heat [ ] Massage/Rubbing [ ] Exercise/Activity [ ] Sitting [ ] Standing [ ] Rest [ ] Stretching [ ] Popping the joints [ ] Bracing/taping [ ] Laying What makes your pain WORSE? (Check all that apply): [ ] Coughing [ ] Sneezing [ ] Bearing Down [ ] Sexual Intercourse [ ] Running [ ] Standing [ ] Lifting [ ] Bending [ ] Pushing [ ] Pulling [ ] Driving [ ] Sitting [ ] Walking [ ] Laying Down [ ] Movement of the head [ ] Movement of the low back [ ] Other Pain Quality: How would you describe your pain/discomfort (check all that apply) [ ] Dull [ ] Achy [ ] Stiff [ ] Intense [ ] Throbbing [ ] Sharp [ ] Sharp with movement [ ] Stabbing [ ] Shooting [ ] Burning [ ] Constricting [ ] Annoying [ ] Tight [ ] Unbearable 1
4 ALEXANDRIA WOODBRIDGE FALLS CHURCH MANASSAS 5130 Duke St Suite Jefferson Davis Hwy. Suite Leesburg Pike, Suite Dorsey Circle Suite 101 Alexandria, VA Woodbridge, VA Falls Church, VA P: (703) P: (703) P: (703) F: (703) F: (703) F: (703) F: (703) Numbness/Tingling (pins and needles): [ ] Yes, [ ] No: Please describe where and when you feel these symptoms: Are symptoms: -Constant >75%- -Frequent 51-75%- -Occasional 26-50%- -Intermittent <25% of your waking hours Have you seen a Chiropractor before? [ ] yes [ ] no Who? When? Reason for visits? How did you respond? Medical Doctors: Name: Date of last visit: Is this your primary care provider? [ ] yes [ ] no Name: Date of last visit: Is this your primary care provider? [ ] yes [ ] no Name: Date of last visit: Is this your primary care provider? [ ] yes [ ] no Surgeries/Hospitalization and dates: Medication: OTC/Persciption/Supplements/Vitamins: Please list all serious illness and serious accidents: Month and Year: City, State: List any allergies to medications, food or other: Are you pregnant? Yes No First day of last menstrual cycle: Do you smoke? Yes No; How much? Do you drink alcohol? Yes No; How much? Please list any recent x-rays, lab or other tests: Month and Year: Facility/Doctor: Do you have a history of any of the following diseases? Tuberculosis Yes Lung Disease Yes Gout Yes Diabetes Yes Kidney Disease Yes Stomach/Ulcer Yes Heart Attack Yes Hepatitis Yes Sciatica Yes Blood Pressure Yes Transfusion Yes Polio / MS Yes Colon Disease Yes Stroke Yes Cancer Yes Bleeding Yes Paralysis Yes Seizures Yes Arthritis Yes Asthma Yes Anemia Yes Thyroid Disease Yes Drug Dependence Yes AIDS Yes Any other condition(s) not listed above that the doctor should be made aware of: 2
5 ALEXANDRIA WOODBRIDGE FALLS CHURCH MANASSAS 5130 Duke St Suite Jefferson Davis Hwy. Suite Leesburg Pike, Suite Dorsey Circle Suite 101 Alexandria, VA Woodbridge, VA Falls Church, VA P: (703) P: (703) P: (703) F: (703) F: (703) F: (703) F: (703) Postural distortions from subluxations in your neck, upper back, middle back and low back will negatively influence and affect the nerves throughout the entire body. Do you NOW or have you EVER experienced: CERVICAL SPINE (NECK): [ ] Neck pain [ ] Headaches [ ] Pain into shoulders/arms/hands [ ] Immune system weakness [ ] TMJ/pain/clicking [ ] Dizziness/fainting [ ] Weakness in grip [ ] Arthritis in the neck [ ] Allergies/ hay fever [ ] Allergies [ ] Visual disturbances [ ] Hearing disturbances [ ] Coldness in hands [ ] Low energy/fatigue [ ] Recurrent colds/flu [ ] Thyroid conditions [ ] Sinusitis [ ] Depression [ ] Numbness/tingling in arms/hands [ ] Anxiety THORACIC SPINE (UPPER BACK): [ ] Upper back pain [ ] Shoulder pain [ ] Heart attacks/angina [ ] Pain on deep inspiration/expiration [ ] Heart palpitations [ ] Tachycardia [ ] Shortness of breath [ ] High blood pressure [ ] Heart murmurs [ ] Asthma/wheezing [ ] High Cholesterol [ ] Recurrent lung infections/bronchitis THORACIC SPINE (MID BACK): [ ] Mid back pain [ ] Pain into ribs/chest [ ] Scoliosis [ ] Kidney disease [ ] Diabetes [ ] Ulcers/gastritis [ ] Indigestion/Heartburn [ ] Hypoglycemia [ ] Gall bladder problems [ ] Nausea [ ] Acid reflux [ ] Tired/irritable after eating or when you haven t eaten for awhile LUMBAR SPINE (LOW BACK): [ ] Low back pain [ ] Pain into hips/legs/feet [ ] Weakness/injuries in hips/knees/ankles [ ] Numbness/tingling in legs/feet [ ] Muscle cramps in legs/feet [ ] Coldness in legs/feet [ ] Recurrent bladder/urinary tract infections [ ] Muscle cramps in legs/feet [ ] Constipation [ ] Menstrual irregularities/ cramping [ ] Diarrhea [ ] Sexual dysfunction [ ] Scoliosis FAMILY HEALTH HISTORY: Have any of your biological family members ever been diagnosed with the following: [ ] Mental Health Disease [ ] Neurological Problems [ ] Lung Disease [ ] Thyroid [ ] Arthritis [ ] Circulatory Problems [ ] Heart Murmur [ ] Cancer [ ] High Blood Pressure [ ] Heart Disease [ ] Stroke [ ] Diabetes [ ] Scoliosis [ ] Kidney Disease [ ] Migraine Headaches RADIOGRAPHY CONSENT: In order to best determine the cause and extent of my underlying spinal problems, I hereby give my consent to allow Virginia Family Chiropractic PM, PLLC to take spine and other relevant radiographs as deemed clinically necessary through chiropractic history/examination and in accordance with clinical usage indications as published in the Practicing Chiropractors Committee on Radiology Protocols for Biomechanical Assessment of Spinal Subluxation in Chiropractic Clinical Practice (2009). Signature of Patient/or Guardian Dat 3
6 Payment Policy ALEXANDRIA WOODBRIDGE FALLS CHURCH MANASSAS 5130 Duke St Suite 114 Alexandria, VA P: (703) F: (703) Jefferson Davis Hwy. Suite 301 Woodbridge, VA P: (703) F: (703) Leesburg Pike, Suite 207 Falls Church, VA P: (703) F: (703) Dorsey Circle Suite 101 F: (703) We provide you with the same information your insurance gives our billing coordinator. If you have any additional questions regarding your benefits or coverage, please contact your insurance carrier directly. Co-payments are to be made at EACH visit. If you have a co-insurance, you will pay a portion at the time of each visit. For example if your portion is 10%, you would pay $10 each visit; 20%, you would pay $20 and so on. You may owe an additional amount which we will collect once your claim has been processed. Patients that have deductibles will be responsible for the contracted rate of your treatment per visit until the deductible has been met. This payment will be applied to your deductible once we receive an explanation of benefits from your insurance carrier. You may owe an additional amount which we will collect once all insurance payments have been applied, or have a credit depending on the claim processing. Referrals: Insurance companies (HMO s) sometimes require their members to obtain a referral from their primary care doctor before seeing a specialist such as a chiropractor. It is your responsibility to obtain a referral if needed, and you must do so prior to your scheduled appointment or you will be forced to reschedule. If a referral is not received, you are financially responsible for any charges incurred for that date of service. Be aware that most referral authorizations are good for a certain number of visits and have an expiration date. If you have any questions about obtaining a referral we will be happy to assist you. The contracted rate is an estimate we have of what your insurance allows. If you have an outstanding balance we will send you (3) statements. If we do not receive payment by the third which is the final statement, further collection action will take place immediately. Should you have any questions regarding the statement, PLEASE CALL US IMMEDIATELY in order to speak with the billing coordinator. Returned Checks: You will be charged a $40 returned check fee if a personal check is returned for nonpayment. A fee of $25.00 is charged if you do not cancel at least 24 hours prior to your scheduled appointment time or no-show. PRINT NAME OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE. DATE SIGNATURE OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE.
7 .,p, ; VIRGINIA FAMILY Chiropractic Ii Phtjsical Medicine Patient History Review of Systems Q ALEXANDRIA Q WOODIIRIOGE FALLS CHURCH MANASSAS 5130 Ouke st Suite 114 Alexandria, VA P: (703) Jefferson Davis Hwy. Suite 301 Woodbridge, VA P: (703) Leesburg Pike, Suite 207 Falls Church, VA P: (703) Dorsey Circle Suite 101 P; (703) F: (703) F: (703) f: (703) S F: (703) = NEVER HAD 1 = PATIENT PRESENTLY HAS 2 = PREVIOUSLY HAD GENERAL MbsaffOSf<ELETAL NEUROLOGICAL Recent weight gain Arthritis Lightheaded/ dizzy Recent weight loss Rheumatoid arthritis Memory loss Fatigue Broken bones Headaches Fever Osteoporosis Migraines Allergies Gout Numbness Loss of appetite Scoliosis Weakness Chills Spinal trauma Stroke Cancer of any kind Joint pain (anywhere} Tingling/Numbess CARDIOVASCULAR RESPIRATORY INTEGUMENT ARY (SKIN) Heart attack Coughing Bruise easily Swelling of ankles Coughing up blood Skin rashes High blood pressure Chronic cough Discoloration Low blood pressure Chest pain Psoriasis Shortness of breath Asthma Changes in moles Pain down left arm Pneumonia Sores Profuse sweating Bronchitis Scars m'x Hioh cholesterol Tuberculosis ltchina EYES, EAR'S.NOSE & THROAT ),I,.,. _..,...,,,...1r,.. L GENITOURINARY Blurred vision Goll bladder problems Painful urination Double vision Liver problems Blood in urine Ear pain Pain over stomach Frequent urination Hoarseness Ulcers Kidney infection Nose bleeds Colitis Kidney stones Glaucoma Hiotol hernia Incontinence Dental problems OTHER /EX PLAINA TIONS: Blood in stool SIGNATURE OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE.
AUTHORIZATION FOR CHIROPRACTIC TREATMENT
AUTHORIZATION FOR CHIROPRACTIC TREATMENT I, the undersigned, a patient in this office, hereby authorize Virginia Family Chiropractic to administer such treatments as is necessary, and to perform the following
New Patient Application. Welcome to Our Clinic!
New Patient Application Welcome to Our Clinic! Welcome and Thank You for applying as a patient to our clinic. We are a very unique team specializing in research-based spinal and postural rehabilitation.
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
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
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
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation. These methods have
562 KINGWOOD DRIVE KINGWOOD, TX Application Form
Application Form WELCOME TO OUR OFFICE. We specialize in helping people achieve their highest level of health through our Neurological, Brain-Based, and Metabolic corrective programs. Our approach is unique
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation that helps our patients
New Member Contact Information
New Member Contact Information Date: Social Security #: - - File Number: First Name: Middle Initial: Last Name: Age: Birth Date: / / Gender: M F Marital Status: S M D W Home Address: Home Phone: - - City,
WELCOME! All our best, Dr. Christopher and Lily Bargmann
WELCOME! We are so glad you re here. Our focus is to help restore normal, healthy function to each of our patients bodies, hopefully allowing them to live a longer, fuller life. Some people are looking
PATIENT APPLICATION FORM
2105 E. Clairemont Ave., Eau Claire, WI 54701 Phone (715)835-9514 Fax (715)835-2602 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level
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
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
PATIENT INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
PATIENT INTAKE FORM WELCOME and THANK YOU for seeking out care at our office. We are a very unique team specializing in research based spinal and postural rehabilitation that helps our patients recover
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
Who may we thank for referring you?
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 /
\ NSMI. The National Sports Medicine InstJtute
~ \ NSMI The National Sports Medicine InstJtute 19455 Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I76 24430 Stone Spring Blvd, Suite 250, Dulles, Virginia 20166 Patient Information: Last Name:
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 /
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
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.
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
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:
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
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
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
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
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
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 /
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
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Welcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
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 #
Chiropractic Registration and History
Chiropractic Registration and History 1. Patient Information Name: Birthdate: SS/HIC/Patient ID #: Address: City: State: Zip: Phone: Cell: E-Mail: Sex: M F (Circle) Minor Single Married Divorced Separated
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
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
PATIENT PERSONAL / CONFIDENTAL DATA
PATIENT PERSONAL / CONFIDENTAL DATA Address: City: State: Zip Code : H. Phone: W. Phone: Cell Phone: Date of Birth: Age: Sex: M F Marital Status: M S D W Email Address: Social Security # Name of Spouse:
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
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
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
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
New Patient Intake Forms. Patient Data Date. Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other. First Name Middle Initial Last Name
New Patient Intake Forms Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address Line City State Zip Code Home Phone ( ) -
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
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
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
Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite
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:
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail
Patient Application Form
Patient Application Form Welcome to our clinic! Our purpose is to help you achieve your highest level of health by providing services that seek to restore and maintain your body to its optimum function.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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:
RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
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:
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
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:
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:
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
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
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
Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
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
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
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:
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
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
NORTHERN VIRGINIA CENTER FOR ARTHRITIS PLEASE PRINT PATIENT REGISTRATION Patient s Name: DOB: Sex: Address: PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER Home#( ) [
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Initial Visit Forms. Life in Motion Chiropractic & Wellness 6139 Route 96 -Suite 1 Farmington, NY (585)
Initial Visit Forms 6139 Route 96 -Suite 1 Patient Name: Patient Intake Form Name: Date: Address: City: State: Zip: Home #: ( ) Cell #: ( ) Work #: ( ) E-mail: Preferred method of contact: Date of Birth:
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
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
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:
PATIENT REGISTRATION
PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
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
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
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female
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
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
History of Present Problem
Patient Name: Date: If you are not the patient: Guardian name: Relationship to Patient: Height: Ft In Weight: lbs Age: Birth Date: Dominant Hand: Right Left Shoe Size: Primary Care Physician: Specialists:
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
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?
(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