Chiropractic for pediatric development and adult health
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1 Raleigh Specific Chiropractic Chiropractic for pediatric development and adult health 7721 Six Forks Rd. Suite 138 Raleigh, NC (919) Items to bring to your first visit: All new patient paperwork filled out in advance Your automobile insurance policy o Claim number o Adjuster s name and phone number o Contact your automobile insurance and open a medical claim 3 rd party automobile policy information o Claim number o Adjuster s name and phone number Your health insurance Your attorney information, if applicable
2 Patient Information -Our mission is to educate and adjust as many families as possible toward optimal health through natural chiropractic care- James K. Winget B.S. DC Jill R. Winget B.S. DC Date Patient No. Name S/S# - - First MI Last (Please Print) Address City: State Zip Home Phone # Work Phone # ext Cell # Sex: Female Male Age Birth Date Are you: Minor Single Married Divorced Widowed Separated Address: Your Employer: Occupation Business Address City State Zip Spouse's or parent's name Workplace Work number Other Person to contact in case of emergency Phone # Whom may we thank for referring you to us? Insurance Information Name of Primary Insurance Company involved Complete Name of the Insured Claims Adjustor's Name Claim# Address Phone# Attorney Information Name Phone# Address City State Zip Health Insurance This office will verify health insurance coverage for you. This is done as a courtesy for you, so please attach Insurance Card if available, and return to chiropractic assistant with this intake request CONFIDENTIAL 7721 Six Forks Rd Ste 138 Raleigh NC office (919) fax (919)
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5 Raleigh Specific Chiropractic Chiropractic for pediatric development and adult health Patient Consents 7721 Six Forks Rd. Suite 138 Raleigh, NC (919) Consent for purposes of treatment, payment and healthcare operations I consent to the use or disclosure of my protected health information by Raleigh Specific Chiropractic for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations of Raleigh Specific Chiropractic. I understand that diagnosis or treatment of me by Dr. James Winget or Dr. Jill Winget may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction. Raleigh Specific Chiropractic is not required to agree to the restriction I may request. However, if Raleigh Specific Chiropractic agrees to a restriction that I request, the restriction is binding on Raleigh Specific Chiropractic and on Drs. Winget. I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. James/Jill Winget or Raleigh Specific Chiropractic has taken action in reliance on this consent. More information regarding this consent is available upon request. Open adjusting area It is the practice of this office to provide chiropractic care in an open adjusting environment. Open adjusting involves several patients being seen in the same adjusting area at the same time. Patients are within sight of one another, and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations, or presenting reports of findings. These procedures are completed in a private, confidential setting. We are requesting this authorization of you due to various interpretations under federal law with respect to what is known as incidental disclosures of health information. It is our view that the kinds of matters related in an open adjusting environment are incidental matters. In the event you are someone else would not agree with us, we are providing this disclosure. The use of this format is intended to make your experience with our office more efficient and productive, as well as to enhance your access to quality health care and health information. If you choose not to be adjusted in an open adjusting environment, other arrangements will be made for you. Your decision will have no adverse effect on your care from Raleigh Specific Chiropractic or on your relationship with our staff. Your signature indicates your authorization of this activity. Your authorization may be revoked by you at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our procedures to be completed. Contact It is our desire for our staff to use your name, address, and/or telephone number for the purpose of contacting you to advise you about health-related meetings, workshops, missed appointments and appointment reminders. The use of this information is intended to make your experience with our office more efficient and productive, as well as to further enhance your access to quality health care. If you choose not to authorize this information use, your decision will have no adverse effect on your care from Raleigh Specific Chiropractic or on your relationship with our staff. This office also occasionally posts stories and x-rays of current patients. If this situation presents itself in your case, this office will obtain specific permission from you for that purpose. Your signature indicates your authorization of this activity. Your authorization may be revoked by you at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our procedures to be completed. Patient Name, Printed Patient Signature Date
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10 Raleigh Specific Chiropractic Chiropractic for pediatric development and adult health 7721 Six Forks Rd. Suite 138 Raleigh, NC (919) Informed Consent for Chiropractic Care Raleigh Specific Chiropractic, Inc Chiropractic care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral artery injury that could lead to stroke. Prior to receiving chiropractic care at this Chiropractic office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spine health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you prior to beginning care. I understand and accept that there are risks associated with chiropractic care and give my consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment. Patient Name (printed) Patient or legal Guardian Signature Witness Signature (office staff) Reviewed by Doctor Relationship to patient Date Date Date
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
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:
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
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
Initial Clinical History and Physical Form
601 E FM 544, Suite 400, Murphy, TX, 75094 TEL: 972-442-4700 Initial Clinical History and Physical Form Patient Information Name: Age: of Birth: / / Sex: Male / Female Marital 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
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to
ADIO CHIROPRACTIC HEALTH PROFILE
ADIO CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
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
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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 /
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 /
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
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
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:
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
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Welcome to our Family Chiropractic Office
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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.
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY
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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
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
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
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
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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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
Chiropractic Case History/Patient Information
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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
Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
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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
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Child s Legal Name: Nickname: Male Female. Birth Date: Age: School: Grade: FATHER STEPMOTHER GUARDIAN? Insured s Name: D.O.B. Social Security #:
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Luker Chiropractic Health Questionnaire
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HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
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First Name: Middle Initial: Last Name: Address Line 1: Address Line 2: Home Phone: ( ) - Work Phone: ( ) - Sex: Female Male Other
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APPLICATION FOR SERVICES
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TRANSITION OF CARE APPLICATION
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