Natural Health Center

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1 Natural Health Center 420 Yucca Lane - Turpin, OK Tel. No. (580) / Cell No. (620) / Fax No. (580) Today s Date / / Application for Treatment Name: Birthdate: SS# Address: City: State: Zip: Home Phone No. Work: Referred to office by: Cell Phone No. Address: Marital Status (please. check one): Married Single Divorced Other Employer: Address: Occupation: Please Describe The Principle Health Problems or Which You Came To This Office: How And When Did Symptoms First Occur? List Any Other Doctors Seen For These Problems: List Diagnosis(es) And Type of Treatment(s): Does The Interfere With Your Normal Living And Work? Yes No If Yes, Explain: List Names o Relatives That Have Or Have Had A Similar Problem: Who is Responsible or Your Bill? (please. Check) Self Spouse Employer Automobile Insurance Workman s Compensation Cash Check Visa Mastercard If Automobile Ins. Or Workman s Comp / Name And Address And Policy Number: Past History Have You Been Treated For Any Health Condition By A Physician In The Last Year? Yes No If Yes, Explain: Have You Or Any Relative Received Chiropractic Treatments Previously? Yes No If Yes, Explain: List The approximate Dates Of Any Operations, Unusual Diseases, Serious Illnesses Or Accidents You Have Had (Include Broken Bones): List All Drugs Or Medication That You Have Used Recently (I.E. Aspirin, Sleeping Pills, Birth Control Pills, Etc.)

2 Family History Name Of Spouse: Ages Of Children: Spouse s Employer: Business phone: Your Nearest Relative: Address: Please Mark Your Areas Of Pain (with an X) On The Figures Below: List Conditions That You Are Most Interested In Getting Corrected. List In Order Of Importance: What Functions Are You Unable To Perform Or That Induce Pain: (I.E. Sitting, Standing, Walking, etc.) List In Order of Severity FEES ARE PAYABLE AT THE TIME X-RAYS, EXAMINATIONS AND TREATMENTS ARE RECEIVED UNLESS OTHER ARRANGEMENTS ARE MADE IN ADVANCE. X-RAYS REMAIN THE PROPERTY OF THIS CLINIC. I HEREBY GIVE PERMISSION OF TREATMENT. I HEREBY AUTHORIZE THE USE OF METHODS DEEMED NECESSARY BY DR. CULLUM. Signature Of Patient Or Guardian Social Security Number

3 Natural Health Center Dr. Dan Cullum, D.C. (580) Yucca Lane Turpin, OK My signature below indicates I understand that I am responsible for the balance in full for services I received here at Natural Health Center. We do not accept any insurance assignment. I am responsible for filing my own insurance so that they may reimburse the services I received. Signature Date

4 Natural Health Center Dr. Dan Cullum, D.C. 420 Yucca Lane Turpin, OK (580) Cancellation policy Due to the nature of our practice we require 24 hour notice for all cancellations. If you fail to provide adequate notice your account will be charged a service charge. Also, if for any reason you should miss your appointment with no notification a service charge will be added to your account. Your signature below indicates that you understand and are responsible for these fees if they should occur. Signature Date

5 Natural Health Center Dr. Dan Cullum, D.C. 420 Yucca Lane Turpin, OK (580) Notice of Privacy Practices Patient Acknowledgment Patient Name: Date of Birth: I have received and understand this practice s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice s legal duties with respect to my information. I understand that this practice reserves the right to change the terms of the Notice of Privacy Practices, and to make changes regarding all protected health information, resident at, or controlled by, this practice. If changes to the policy occur, the practice will provide me a revised Notice of Privacy Practices upon request.. Signature: Date: Relationship to patient (if signed by a personal representative of patient):

6 NATURAL HEALTH CENTER DAN CULLUM, D.C.based 420 YUCCA LANE TURPIN, OKLAHOMA Request and Consent For Treatment I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures. Including but not limited to, various modes of physical modalities and diagnostic x-rays on me, (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named above and/or other licensed doctor of chiropractic, who now or in the future treat me while employed, working, or associated with, or serving as back up for the doctor of chiropractic named above, including those working at the clinic or office listed below or any other office or clinic. I have had an opportunity to discuss with the doctor of chiropractic, named above and/or with other office or clinic personnel, the nature and purpose of chiropractic and other procedures. Including that the results are not guaranteed. I understand and am informed that, as in the practice of medicine as well as in the practice of chiropractic there are some risks to treatment, including but not limited to, fractures, injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. I wish to rely on the knowledge of the doctor of chiropractic named above to exercise his judgment during the course of the procedure, based upon the facts that are then known, is in my best interest. I have read or have had read to me the above consent. I have also had the opportunity to ask any questions about this consent. By signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present conditions and/or any future conditions for which I seek treatment from the doctor of chiropractic named above.. Print Patients Full Name Patients Signature Date Print Patients Authorized Representatives Name Patients Authorized Representatives Signature Date Authorized Representatives Relationship To Patient Print Patients Full Name

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