Patient Information Form

Patient Information Name: First Middle Last Address: City: State: Zip: Telephone: Home Cell Work Date of Birth: Social Security Number: (SSN is only needed if getting super-bills for potential insurance reimbursement) Employer: Occupation: Would you like to receive email updates? Y N Have you previously seen a chiropractor? Y N Email address: Date of Last Visit: Previous Chiropractor Name: City: Reason for Leaving: Present Medical Doctor: City: How did you hear about Isle of Sky Chiropractic Wellness Center? Patient Information Form

Adult Consultation History Name: First Middle Last Main Complaint: Any Other Complaints: How long have you suffered with this problem? What have you tried to do to in the past to get rid of this problem that DID NOT work? Are you feeling discouraged about handling this problem? Y N When your problem is at it s worst, how does it make you feel? How does this problem interfere with the following areas of your life? Work: Family: Hobbies: Life: Does handling this problem cause stress for you? What do you do that makes this problem worse? How much older does this make you feel? On a scale of 1 to 10, with 10 being the highest, rate your commitment in helping us solve this problem: 1 2 3 4 5 6 7 8 9 10 What gives you some temporary relief? Adult Consultation History Form Page 1

What is the pattern of this problem? Constant Intermittent Occasional Cyclic What is the effect it has on your body functions? How did it start? Are you on any type of medication? Y N If so, please list: Could your problem have been caused by an injury at work? Y N If yes, please give us the details: Have you been involved in an auto accident? Y N Date of Accident: Any difficulties from this? Do you have any children? Y N Do they have any health problems that you are aware of? Is there any other information you would like us to know? For Women Only Date of your last menstrual period? Do you suffer from PMS? Y N Do you experience severe cramping with your menstrual period? Y N Are you using any means of contraception? Y N Thank You! Adult Consultation History Form Page 2

Our Fee Structure Last Updated on 8/4/2011 We have found that insurance companies typically do not support the quality, amount and type of health care coverage that is necessary for optimal health. In order to focus on the needs of the patient and deliver the best care possible, Dr. Seward has chosen to be an out-of network insurance provider. Payment options: Payment is due upon the day of your visit. We will provide you with a super-bill to file on your own to your insurance company. To better serve our community, we give up to a 30% discount for individuals/families who choose to invest in their health with prepay plans. These packages must be used within the first 3 months after your first visit. See Dana for more information! In most cases this option is less costly than using your insurance, due to high deductibles and limited insurance coverage. **Discounts are not available for use with any insurance or Medicare. We are currently not accepting Medicare or Medicaid. Fees for Your Initial Visit: Consultation...Complimentary Examination...$50 Radiology... $40/ $60/ Maximum $80 Dependent on Views Adjustment...$45 Package Prices Available Estimated Total... Maximum $175 Fees After Your Initial Visit: Adult Adjustment... $45 Package Prices Available Child Adjustment... $25 Package Prices Available Re-examination... $20 Doctor s Report... $20 Due Upon 2 nd Visit Nutritional Assessment... $45 * Please note that if you have been involved in a motor vehicle accident, our fee structure may differ due to the complexity of your needs in such cases. * Please also note that your clinical Report of Findings, the time that Dr. Seward will spend with you to go over your results, will be $20.00, due upon your second visit. * Adult and Child Packages expire after 6 months of initial purchase. I fully understand the above fees and give my consent. I also give my consent to have the doctor take any x-rays he deems appropriate to better understand my problem and monitor my progress. All x-rays are performed on premises by Dr. Seward. Fee Structure Acceptance Form

Informed Consent to Chiropractic Treatment The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a click or a a pop such as the noise when a knuckle is cracked and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or hydrotherapy may also be used. Possible risks: As with many health care procedures, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications. Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as rare, about as often as complications are seen from taking a single aspirin tablet. The risk of cerebrovascular injury or stroke has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due ancillary procedures is also considered rare. Other treatment options which could be considered include the following: Over-the-counter analgesics. The risks of these medications include irritation to the stomach, liver and kidneys, and other side effects in a significant number of cases. Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases. Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable diseases in a significant number of cases. Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases. Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue, and other degenerative changes. These changes can further reduce skeletal mobility and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make further rehabilitation more difficult. Unusual risks: I have had the following unusual risks of my case explained to me. I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment. Printed Name: Date: Signature: Witness: Informed Consent to Chiropractic Treatment Form

Terms of Acceptance I have been informed and fully understand that Chiropractic care is not the treatment of any disease or condition. I understand that the body is a self-healing organism, that the nervous system is the master controller of the body and that any interference to the function of the nervous system creates a malfunction within the body. I understand that vertebral Subluxations interfere with the function of my nervous system and produce poor health expression. I also understand that my care is aimed at correction of my vertebral Subluxations thereby restoring or optimizing my health potential. Name of Patient: Date: Signature: Witness: Thank You! Terms of Acceptance

Use of Name & Photo Authorization I,, authorize Isle of Sky Chiropractic, PLLC to use my name or picture for any of the following: Use of my name and/or photo in advertising of any kind Use of my name in any type of testimonial Use of my name on an internal thank you board Use of the photo of a child for the kid s wall Use of my photo for the patients wall Use of my name and/or photo on the ioschiro.com website This notice is effective as of the date below and expires seven years from the date I last received services in this office. Patient s Printed Name: Authorized Provider Representative: Personal Representative s Printed Name: Representative s Signature: Date: Description of Personal Representative s Authority to Act for the Patient: Thank You! Use of Name & Photo Authorization Form

Privacy Notice Acknowledgement We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy policies and procedures. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use or dissemination of your personal health information we would be happy to address them. I acknowledge that I have received a copy of the Isle of Sky Chiropractic, PLLC s Notice of Privacy Practices for Protected Health Information. Patient s Printed Name: Authorized Provider Representative: Personal Representative s Printed Name: Representative s Signature: Date: Description of Personal Representative s Authority to Act for the Patient: Thank You! Privacy Notice Acknowledgement Form

Appointment Reminders & Health Care Information Authorization At times our office may need to contact you with appointment reminders, information about treatment or other health related information. By signing below, you are giving us authorization to contact you with these reminders/information and understand that I may be contacted by: Phone (home, work, cell) Email Postcard Messages may be left: On answering machine/voicemail at home, work, or cell Or with individuals answering phone at home or work Information that we use or disclose based on this authorization may be subject to re-disclosure by anyone who has access to the reminder or information and may no longer be protected by the federal privacy rules. You may register the individuals of organizations to which your health care information is released, or remove you authorization at any time; however, the revocation must be in writing and will become effective once we receive the revocation. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. You have to right to refuse any part of this authorization without affecting your treatment or the methods used to obtain reimbursement for your care. You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time (164.524). I authorize the use or discloser of my health information as described above. This notice is effective as of the date below and expires seven years from the date I last received services in this office. Patient s Printed Name: Signature: Date: Authorized Provider Representative: Personal Representative s Printed Name: Representative s Signature: Date: Description of Personal Representative s Authority to Act for the Patient: Appointment Reminders & Health Care Info Authorization Form