EMERGENCY CONTACT INFORMATION

LANDMARK CHIROPRACTIC Dr. Cole D. Bergeson 204 Bevins LN D, Georgetown, KY 40234 Ph (502) 868-6008 Fax (502) 868-6087 Name: Preferred Name: Address: City: State: Zip: Home: Mobile: Mobile Carrier: Work: Email: Gender: M / F of Birth: Social Security #: Referred By: Marital Status: Married / Single / Divorce Employer: Full Name: Home: Mobile: General: Recent Weight Change Fever Fatigue Musculoskeletal: Low Back Pain Mid Back Pain Neck Pain Arm Problems Leg Problems Stiff/Swollen Joints Sore/Weak Muscles or Joints Muscle Spasms/Cramps Other: Neurological: Numbness or tingling sensations Loss of feeling Dizziness or light header Convulsions or seizures Tremors Stroke Have you ever had a head injury? Ever been in an auto accident? Mind/Stress: Nervousness Depression Sleep Problems Memory Loss or Confusion Other: Genitourinary: Sexual Difficulty Kidney Stones Burning/painful Urination Change in force/strain with Urination Frequent Urination Blood in Urine Incontinence or Bed Wetting Other: EMERGENCY CONTACT INFORMATION Employer Address: Primary Care Physician: Doctor s Phone: CURRENT SYMPTOMS Gastrointestinal: Loss of appetite Blood in Stool Change in bowel movements Painful bowel movements Nausea or Vomiting Abdominal pain Frequent Diarrhea Constipation Other: Cardiovascular & Heart: Chest Pains Rapid or Heartbeat changes Blood pressure problems Swelling of hands, ankles, or feet Heart problems Other: Respiratory: Difficulty breathing Persistent cough Coughing blood Asthma or wheezing Lung problems Other: Endocrine, Hematologic, & Lymphatic Thyroid problems Diabetes Excessive thirst or urination Cold extremities Heat or cold intolerance Dry skin Glandular or hormone problem Swollen glands Anemia Easily bruise or bleed Transfusion Immune system disorder Ears, Nose, & Throat: Bleeding gums / mouth sores Bad breath or bad taste Dental problems Swollen throat or voice change Swollen glands in neck Ear - ache/ringing/drainage Sinus / Allergy problems Nose bleeds Hearing loss Eyes & Vision: Wear contacts/glasses Blurred or double vision Glaucoma Eye disease or injury Other: Skin & Breasts: Rash or itching Change in skin color Change in hair or nails Non-healing sores Change of appearance of a mole Breast pain Breast lump Breast discharge Women Only: Are you pregnant? Yes - Due / / No - Last Menstrual Period / / Infertility Painful or irregular periods Vaginal discharge

PAST HEALTH HISTORY What treatment(s) have you received for this condition? Medical/Medications Surgery Chiropractic Massage Physical Therapy None Other Name of the provider who gave previous services? of last: Physical Exam MRI/CT Scan X-rays Blood Test Please mark any of the following past conditions that apply: Acid Reflux AIDS/HIV Alcoholism/Drugs Allergy Shots Anemia Arthritis Asthma Bronchitis Cancer Diabetes Eating Disorder Emphysema Epilepsy Fractures Gout Heart Disease Hepatitis Hernia Herniated Disc High BP High Cholesterol NO SURGERIES Kidney Disease Migraines Osteoporosis Pacemaker Parkinson s Pinched Nerve Pneumonia Prostate Problem Rheumatoid Arthritis Stroke Thyroid Problems Tumors, Growths Other SURGERIES AND DATE PERFORMED: FAMILY HISTORY Please mark any of the following that apply to your family health history: Cancer Diabetes Heart Disease High Blood Pressure Rheumatoid Arthritis Stroke Other MEDICATIONS Please list ALL current medications. If you have a list, please give to the receptionist to make a copy. MEDICATIONS REASON FOR MEDICATION EXERCISE None Light Moderate Heavy SOCIAL HISTORY WORK ACTIVITY Sitting Standing Light Labor Heavy Labor HABITS Smoking Alcohol Coffee/Caffeine Drinks High Stress Level I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. PATIENT SIGNATURE: DATE:

NAME: DATE: NECK PAIN / HEADACHE Specifically, where is your neck pain? When did your neck pain begin? Your neck pain started: Suddenly Gradually If suddenly, what caused your neck pain? Rate the severity of your neck pain (mild) 1 2 3 4 5 6 7 8 9 10 (severe) Your neck pain is present roughly what percentage of your awake time? 0-25% 26-50% 51-75% Intermittent Occasional Frequent 76-100% Constant Your neck pain is getting: Better Worse Staying the same Your neck pain is: Burning Cramping Shooting Throbbing Dull Sharp Stiff Tingling Other Your neck pain Looking Up Looking Down Looking Right Looking Left is worse when: Reading Sleeping Driving Computer/Phone use Coughing/Sneezing Nothing Specific Other Your neck pain Ice Heat Stretches Medication Chiropractic improves with: Rest Massage Nothing Other Does the neck pain Work Sleep Daily Routine Recreation interfere with: Does not interfere Other Does your neck pain travel into: Left Shoulder Left Arm Left Hand Does Not Travel (Check all that apply) Right Shoulder Right Arm Right Hand Other Your neck pain is worse: AM After Work No Specific Time/Activity PM After Activities Other Do you have headaches? No Yes If yes, how many times per week? Is the headache: Right Sided Left Sided Behind Eyes Base of Skull Wraps Around Your headache is triggered by: Light Smell Sound Stress Neck Pain Nothing Specific Other

MID BACK Specifically, where is your mid back pain? When did your mid back pain begin? Your mid back pain started: Suddenly Gradually If suddenly, what caused your mid back pain? Rate the severity of your mid back pain (mild) 1 2 3 4 5 6 7 8 9 10 (severe) Your mid back pain is present roughly what percentage of your awake time? 0-25% 26-50% 51-75% Intermittent Occasional Frequent 76-100% Constant Your mid back pain is getting: Better Worse Staying the same Your mid back pain is: Burning Cramping Shooting Throbbing Dull Sharp Stiff Tingling Other Your mid back pain Pushing Bending Laying Pulling Twisting Lifting is worse when: Sitting Nothing Specific Other Coughing/Sneezing Deep Breath Your mid back pain Ice Heat Stretches Medication Chiropractic improves with: Rest Massage Nothing Other Does the mid back pain Work Sleep Daily Routine Recreation interfere with: Does not interfere Other Your mid back pain is worse: AM After Work No Specific Time/Activity PM After Activities Other

LOWER BACK Specifically, where is your low back pain? When did your low back pain begin? Your low back pain started: Suddenly Gradually If suddenly, what caused your low back pain? Rate the severity of your low back pain (mild) 1 2 3 4 5 6 7 8 9 10 (severe) Your low back pain is present roughly what percentage of your awake time? 0-25% 26-50% 51-75% Intermittent Occasional Frequent 76-100% Constant Your low back pain is getting: Better Worse Staying the same Your low back Burning Cramping Shooting Throbbing Dull pain is: Sharp Stiff Tingling Other Your low back pain is Lifting Sitting Bending Twisting Laying worse when: Standing Changing Positions Walking/Running Using Restroom Coughing/Sneezing Nothing Specific Other Your low back pain Ice Heat Stretches Medication Chiropractic improves with: Rest Massage Nothing Other Does the low back pain Work Sleep Daily Routine Recreation interfere with: Does not interfere Other Does the low back pain travel into: Left Thigh Left Calf Left Foot Does not travel (Check all that apply) Right Thigh Right Calf Right Foot Other Your low back pain is worse: AM After Work No Specific Time/Activity PM After Activities Other Any recent changes with bowel or bladder function? No Yes Explain I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. PATIENT SIGNATURE: DATE:

Please mark your areas of pain on the diagram below. Please list and describe any other complaints/concerns you are having that you did not address above.

Landmark Chiropractic TERMS OF ACCEPTANCE I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of Chiropractic, Dr. Cole Bergeson, office assistants, or any other staff members. I have had the opportunity to discuss the nature and purpose of chiropractic adjustments and other procedures. I understand that the results are not guaranteed. I acknowledge that it has been explained to me that the diagnostic and treatment procedures to be provided are limited to Chiropractic treatment and that it might be necessary for me to select another physician and obtain from him/her a complete diagnosis of my condition and such continued treatment as he/she may prescribe. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I acknowledge that Dr. Bergeson has explained any risk with my condition, I understand, and agree to be treated. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to them, is in my best interest. I hereby release Dr. Bergeson, Landmark Chiropractic, and any staff members from any and all liability of injury sustained no matter cause or reason. By signing this agreement, I will not hold Dr. Bergeson or his staff liable for any and all injuries sustained on the premises whether unintentional, accidental, or acts of God or any other classification of injury. I understand that with any adjustment or therapy, there is a risk of muscle soreness, stiffness, ache, headaches, pain, dizziness, and other symptoms after treatment and that this is common with chiropractic. I have been advised of these side effects and would like to continue with treatment. I have read all of the above terms of acceptance. Signature Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your PHI we encourage you to read the HIPPA Notice that is available to you at the front desk before signing this consent. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. The patient has the right to examine and obtain a copy of his/her own health records at any time and request correction. The patient may request to know what disclosure have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. A patient s written consent need only be obtained one time for all subsequent care given the patient in this office. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operation, our office has the right to refuse to give care. Signature X Ray Release This is to certify that the Drs. Of Landmark Chiropractic have my permission to perform an X Ray evaluation. To the best of my knowledge I am not pregnant and I have been advised that x ray can be hazardous to an unborn child. of last menstrual cycle: Signature Consent to Care for Minor I authorize the Drs. Of Landmark Chiropractic and whomever they may designate as his assistant to administer care as he so deems necessary to my so/daughter. Signature

FINANCIAL POLICY Landmark Chiropractic is committed to serving you to the best level possible. We as that you read and understand our financial policy as it applies to your particular situation. Billing Bills will be sent for all covered services (after deductible has been met) after hearing from your insurance company. Any outstanding balances are billed on the 1 st and 15 th of the month and considered past due 30 days after the invoice date or when special arrangements are not met. 8% interest will be charged monthly on all accounts past due. Landmark Chiropractic reserves the right to send any past due account to collections after 120 days. If you are experiencing financial difficulties, please let us know and we will gladly work with you to set up a payment plan. Cash Payment Landmark Chiropractic is pleased to offer EVERYONE a time of service discount. A Time of Service Discount is a discount off of our standard fee schedule here at Landmark Chiropractic. This discount is available to any and all patients making payment at the time of service. Payment can be made via check, cash, or credit card. There are many administrative costs and extra tasks that must be completed when processing insurance claims. A patient paying at the time of service greatly lessens this workload which allows us to pass a significant savings on to both the patient and their insurance company for those patients who submit their own claims to the insurance company for reimbursement or are self pay. This discount does not apply to nutritional supplements, customized orthotics or supplies. Insurance The doctor in this office is a provider for several insurance plans. We will call to verify benefits as each individual and group plan may have different benefits, coverage, and deductibles. Our office will file the necessary claim forms at no charge. Patients are responsible for all co payments and non covered services. Payment for non covered services and co payments will be collected at the time of service and can be paid for insurance if the deductible exceeds $500. We will offer these patients the choice to use the insurance or pay a time of service discount. If the patient chooses to use their insurance, we reserve the right to collect up to $35 at the time of service to put towards their deductible. Copayments, co insurance, deductibles and patient responsibilities vary by company y and plan. Medicare The doctor in this office is a Medicare provider. We will submit all claims to Medicare and secondary plans for you. The only chiropractic service Medicare reimburses for is manual manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. If you have a supplement plan, they will normally cover the other 20% of the allowable fee once the Medicare deductible has been met. You are responsible for payment in full for non covered services at the time of service. This would include X Rays, examinations, therapies, nutritional supplements and supports. If you do not have a supplement plan, you are responsible for the 20% that Medicare does not reimburse as well as any non covered services listed above at the time of service. Personal Injury / Automobile Accidents / Worker s Compensation If you have been involved in a motor vehicle accident / injured on the job, it is important that you report the accident to your insurance agent / employer and request a claim number and the appropriate billing information. We will submit your claims at no charge. Although you as the patient are ultimately responsible for the bill, we will take assignment as long as you are under active care. Once the claim is settled, or if you suspend or terminate care, any fees for services are due immediately. The patient also agrees to have payment made directly to Landmark Chiropractic and not to the patient. Special Arrangement We have never denied anyone the benefits of chiropractic care because of their inability to pay our published fees. If financial hardship exists, it requires an additional form. Please speak with the front desk staff for more information. PATIENT AGREEMENT I understand that my insurance is an arrangement between myself and my insurance company, NOT between Landmark Chiropractic and my insurance company. I request that Landmark Chiropractic prepare the customary forms at no charge so that I may obtain insurance benefits. I also understand that if my insurance company does not respond within 60 days, or if I suspend or terminate my schedule of care as prescribed by Dr. Bergeson, that fees will be due and payable immediately. I understand that charges will be made for treatment for the use of x rays, laboratory, diagnostic testing and any other service performed in accordance with the prescribed treatment plan all of which I agree to pay. I hereby assign all insurance benefits that may arise to Landmark Chiropractic. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that should the status of my account become delinquent, any charges resulting from the collection of said account are incurred by me. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and 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 condition and for any future condition(s) for which I seek treatment. I understand that some or all services provided for me might not be covered by my contract benefits. I understand that all services rendered me are charged directly to me and I am personally responsible for payment. By signing below, I acknowledge that I have read and accepted the financial policy of Landmark Chiropractic. Patient s Signature (or guardian if minor)