Aspire Chiropractic & Massage
22124 NE Glisan St.
Gresham OR, 97030
Ph:(503) 618-0147
Fax: (503) 618-0148

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information


Personal Information
Contact Information
Feet Inches
   
 

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)

   

How did you find out about our office?


Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Personal Health History


Family/Primary Physician

Separate details with "," comma as shown above.



Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Personal Incident History:


If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History


Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Chiropractic Experience

Please select all that apply.

Other:

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Health Problems & Concerns:


Please select all that you have had or currently have.

Authorization

HIPPA/Privacy StatementHIPPA Privacy Statement Health Insurance Portability & Accountability Act Statement (HIPPA) I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors and massage therapist see medically necessary based on my condition. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. Additonally I am signing below and understand Aspire Chiropractic's Privacy Practices, also known as the Health Insurance Portability and Accountability Act (HIPPAA). The notice below describes how related information about you may be used and disclosed and how you can get access to the information. You can request a copy of this at anytime in our office. I consent to the use or disclosure of my protected health information by Aspire Chiropractic for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations for Aspire Chiropractic. I understand that diagnosis or treatment of me by Aspire Chiropractic may be conditioned upon my consent as evidenced by my signature on this document. 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 health care operations of the practice. Aspire Chiropractic is not required to agree to the restrictions that I may request. However, if Aspire Chiropractic agrees to a restriction that I request, the restriction is binding on Aspire Chiropractic. I have the right to revoke this consent, in writing, at any time, except to the extent that Aspire Chiropractic has taken action in the reliance on this content. 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 understand I have a right to review Aspire Chiropractic’s Notice of Privacy Practices prior to signing this consent document. The Aspire Chiropractic Notice of Privacy Practices has been offered and/or provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment or my bills or in the performance of health care operations of the Aspire Chiropractic. This Notice of Privacy Practices also describes my rights and the duties of Aspire Chiropractic with respect to my protected health information. Aspire Chiropractic reserves 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 Aspire Chiropractic’s office and requesting a revised copy be sent in the mail or asking the one at the time of my next appointment. Insurance information I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that this chiropractic office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this chiropractic office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. Consent to Use or Disclose Health Information By signing below I authorize Aspire Chiropractic to use and disclose the health and medical information, via fax, mail or electronically for the purposes of Treatment, Payment and Health Care.

Name of the Insured:
(Please Print)
_____________________________________________    
Patient's/Guardian's signature:
_____________________________________________
Date:
__________

Signature


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