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 Ht: Wt: Relationship to Patient Email Integrative Sports & Wellness Dr. Russell Jepson, DC Dr. Casey Garman, DC 11420 FM 2244 Suite A-100 Austin, TX 78738 Phone: (512) 263-9961 www.integrativesportsandwellness.com Insurance Info Address City ASSIGNMENT AND RELEASE State Zip I certify that I, and/or my dependent(s), have insurance coverage with Home Phone ( ) and assign directly to Cell Phone ( ) Name of Insurance Company [ ] Married [ ] Widowed [ ] Single [ ] Minor Dr. all insurance benefits, [ ] Separated [ ] Divorced [ ] Partner if any, otherwise payable to me for service rendered. I understand that financially responsible for all charges whether or not paid by insurance. Occupation I am authorize the use of my signature on all insureance submissions. Patient Employer/School The above-named doctor may use my health care information and may Spouse's Name disclose such information to the above-named Insurance Company(ies) Spouse's Birthdate and their agents for the purpose of obtaining payment for services and deterring insurance benefits or the benefits payable for related services. The consent will end when my current treatment plan is completed or one year from the date signed below. Signature of Patient, Parent, Guardian or Personal Representative Print name of Patient, Parent, Guardian or Personal Representative Whom may we thank for referring you? Relationship to Patient Emergency Information Accident Information In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No Name Type of accident [ ] Auto [ ] Work [ ] Home [ ] Other Relationship Do you have Personal Injury Protection (PIP) Coverage or Liability Coverage Phone ( ) Attorney Name (if applicable) Patient Condition Reason for your visit? When did your symptoms appear? Is this condition getting progressively worse? [ ] Yes [ ] No [ ] Unknown Mark an X on the picture where you continue to have pain [P], numbness [N], or tingling [T]. Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain: [ ] Sharp [ ] Dull [ ] Throbbing [ ] Numbness [ ] Aching [ ] Burning [ ] Shooting [ ] Cramps [ ] Tingling [ ] Swelling [ ] Stiffness [ ] Other How often do you have this pain? Is it constant or does it come and go? Does it interfere with your [ ] Sleep [ ] Work [ ] Recreation [ ] Daily Routine Activities that are painful to perform [ ] Sitting [ ] Standing [ ] Bending [ ] Walking [ ] Lying Down
Health History What treatment(s) have you received for your condition? [ ] Medications [ ] Surgery [ ] Physical Therapy [ ] Chiropractic [ ] Massage Therapy [ ] Acupuncture [ ] Other Name of the Office and the Name of the other Doctor(s) who have treated you for this condition: Name of the Office and the Name of your Primary Care Physician: Place a mark on "Yes" or "No" to indicate if you have had any of the following: Anemia [ ] Yes [ ] No High Cholesterol [ ] Yes [ ] No Arthritis [ ] Yes [ ] No Common Headaches [ ] Yes [ ] No Concussion [ ] Yes [ ] No Migraine Headaches [ ] Yes [ ] No Diabetes [ ] Yes [ ] No Multiple Sclerosis [ ] Yes [ ] No Heart Disease [ ] Yes [ ] No Osteoporosis [ ] Yes [ ] No High Blood Pressure [ ] Yes [ ] No Pinched Nerve [ ] Yes [ ] No Herniated Disc [ ] Yes [ ] No Stroke [ ] Yes [ ] No Work Activity Exercise Habits [ ] Sitting [ ] None [ ] Smoking Packs/Day: [ ] Standing [ ] Moderate [ ] Alcohol [ ]Coffee [ ]Caffeine Drinks [ ] Light Labor [ ] Daily [ ] Heavy Labor [ ] Heavy Please List: Family Health History (Heart Attacks, Diabetes, Cancer..etc) Are you pregnant? [ ] Yes Due Injuries/Surgeries: Falls Head Injuries Broken bones Dislocations Surgeries Description Medications (Dosage & Start ) Allergies Vitamins/Herbs/Supplements
Integrative Sports and Wellness Medical Center Casey Garman, DC Russell Jepson, DC Bryan Jepson, MD 11420 FM 2244 Suite A-100, TX 78738 Phone: (512) 263-9961 Fax: (512) 263-9963 Informed Consent for Examination and Treatment I (we) hereby consent to the performance of examination and treatment on me or on, by the licensed doctors of chiropractic, medical doctors, chiropractic assistants, registered dieticians, and/or licensed massage therapists who may be employed by or engaged in practice in this clinic. I have had an opportunity to discuss with the doctor(s) or other clinic personnel the nature and purpose of the different therapeutic modalities offered here, including physiotherapy procedures, chiropractic treatment(s) (manipulations/adjustments),massage therapy, nutritional counseling, and focused medical intervention.. I understand that neither chiropractic nor medical treatment is an exact science and that my care may involve judgments based upon facts and information known to the doctor. The doctor uses this judgment to attempt to anticipate or explain risks and complications and an undesirable result does not necessarily indicate an error in judgment. No guarantee for results can be made or expected but rather I wish to rely on the doctor to choose and recommend a best course of treatment, based upon facts known, that is in my best interest. I further understand that there are certain degrees of risk associated with medical therapy, chiropractic health care and physiotherapy, which includes rarely, but are not limited to, medication reactions, supplement reactions, fractures, disc injuries, strokes, and soft tissue strains/sprains and I am therefore willing to accept and consent to the risk associated with the care that I am about to receive. I also understand that the care received at Integrative Sports and Wellness Medical Center is specialized and complementary in nature to the care that I receive from my primary care physician and should not be considered as a replacement to that primary care. I understand that I should maintain my relationship with my primary care physician for all other routine medical services that are not offered at this specialty clinic. I have read, or the above information has been explained regarding consent. I have had an opportunity to ask questions about my examination and treatment. By signing below, I agree and intend this consent form to cover the procedures prescribed for my condition and for my future conditions for which I seek treatment. Patient s Name (Print) Relationship or authority if not signed by patient Patient s Signature
ISWMC OFFICE FINANCIAL POLICY If You Do Not Have Insurance: All cash payments are expected at the time of service or by an authorized payment plan. Our payment plans make care an affordable part of your family budget. If You Do Have Insurance: All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Upon your first appointment we will give you a review of your insurance benefits as the best of our knowledge based inquiries. These are estimated benefits, not guaranteed by your insurance. We agree to file insurance claim forms to your carrier for all services rendered in our office. If your insurance denies a claim for any reason, it is your responsibility to pay the outstanding balance of the charges. Returned Check Fee: For any checks returned to us for insufficient funds, you will be charged $50.00 per check for processing fees. Cancellation Policy: Patients that do not honor their appointments will be charged a cancellation fee. The fees are as follows: Chiropractic/Rehab: $20 fee unless canceled prior to appointment Massage Therapy: Must be canceled the day before the appointment or $30 fee for an Hour Massage $20 fee for a ½ Hour Massage Our fees are considered to be usual, customary and reasonable by most insurance companies. Because we are in network with many carriers and have contractual agreements with them, we are obligated to collect all co-pays and deductible amounts. Patient s Printed Name: Signature: : ISWMC Email Communication Release I,, understand that email communication with Integrative Sports and Wellness Medical Center is not encrypted and my personal health information (including medical history, exam results, treatment plans, and lab results) may be intercepted and viewed by a third party. I release all liability of Integrative Sports and Wellness Medical Center and its employees and affiliates. I would like my personal health information delivered to me through (please check all that apply): Email Postal mail In person Patient (or Parent) Signature
Integrative Sports and Wellness Medical Center Consent for Purposes of Treatment, Payment & Healthcare Operations In this document, I and my refer to the patient, and Chiropractor and/or Medical Doctor refers to Integrative Sports and Wellness Medical Center, Russell Jepson DC, Casey Garman DC, or Bryan Jepson MD. I consent to the use or disclosure of my protected health information by Chiropractor and/or Medical Doctor for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Chiropractor and/or Medical Doctor. I understand that analysis, diagnosis or treatment of me by Chiropractor and/or Medical Doctor may be conditioned upon my consent as evidenced by my signature below. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Chiropractor and/or Medical Doctor are not required to agree to the restrictions that I may request. However, if Chiropractor and/or Medical Doctor agree to a restriction that I request, the restriction is binding on Chiropractor and/or Medical Doctor. I have the right to revoke this consent, in writing, at any time, except to the extent that Chiropractor and/or has taken action in reliance on this Consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I have been provided with a copy of the Notice of Privacy Practices of Chiropractor and or Medical Doctor and understand that I have a right to review the Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiropractor and or Medical Doctor. The Notice of Privacy Practices for Chiropractor and or Medical Doctor is also posted in the waiting room at 11420 FM 2244 Suite A-100 Austin, Tx 78738. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor and/or Medical Doctor with respect to my protected health information. Chiropractor and or Medical Doctor reserve the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of Chiropractor and/or Medical Doctor and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. Signature of Patient or Personal Representative Printed Name of Patient of Signing Description of Personal Representative s Authority
QUADRUPLE VISUAL ANALOGUE SCALE Patient Name Please read carefully: Instructions: Please circle the number that best describes the question being asked. Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: Headache Neck Low Back 1 What is your pain RIGHT NOW? 2 What is your TYPICAL or AVERAGE pain? 3 What is your pain level AT ITS BEST (How close to 0 does your pain get at its best)? 4 What is your pain level AT ITS WORST (How close to 10 does your pain get at its worst)? OTHER COMMENTS: Examiner Reprinted from Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, 855-862, 1993, with permission from Elsevier Science.