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.
Welcome to our office of chiropractic. Thank you for taking a moment to fill in
our Patient Intake Form. Please fill this form completely
and to the best of your knowledge. Let our staff know if you have any questions.
When complete return it to our office with the bottom authorization checked and
appropriate signatures filled in.
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
|
|
|
|
|
|
|
|
(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.)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Draw Your Symptoms
![]()
Click on a crayon and draw on the body above to indicate your symptoms
Current Symptoms
If Yes, Explain:
If yes:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Explain:
If Yes, Where?
Personal Incident History:
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:
Reason for this Visit
If you're only here for chiropractic wellness services please skip this section.
Does this concern interfere with:
Results:
Goals for Your Care
People see a chiropractor for a variety of reasons. Some go for relief of pain,
some to correct the cause of pain and others for correction of whatever is malfunctioning
in their body. Your doctor will weigh your needs and desires when recommending your
care program. Please check the type of care desired so that we may be guided by
your wishes whenever possible.
Health Problems & Concerns:
Please select all that you have had or currently have.
Authorization
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 see fit. 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. Medical doctors, Chiropractic doctors, Osteopaths, and Physical Therapists who perform manipulation are required by law to obtain your informed consent before starting treatment. I do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations / adjustments involving movement of the joints and soft tissues. Physical therapy and exercises may also be used. Although spinal manipulation/adjustment is to be considered one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with procedures as follows. Soreness: I am aware that like exercise it is common to experience muscle soreness in the first few treatments. Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. Fractures / Joint injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disk, or other abnormality is detected, this office will proceed with extra caution. Treatment results: I also understand that there are beneficial effects associated with treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However I appreciate that there is no certainty that I will receive these benefits. Alternative treatments available: Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription or over the counter medications, exercises, and possible surgery. Medications: Medication can be used to reduce pain or inflammation. I am aware that long term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short term relief, undesirable side effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks. Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat, or other home therapy. Prolonged bed-rest contributes to weakened bones and joint stiffness. Exercises are of limited value but are not corrective of injured nerve and joint tissues. Surgery: Surgery may be necessary for joint instability or serious disk rupture. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, or prolonged recovery. Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar / adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthy. I have read or have had read to me the above explanation of chiropractic treatment. Any questions I have had regarding these procedures have been answered to my satisfaction prior to my signing this consent form. I have made my decision voluntarily and freely. To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.
|
Name of the Insured:
(Please Print)
|
_____________________________________________
|
|
|
|
Patient's/Guardian's signature:
|
_____________________________________________
|
Date:
|
__________
|
Signature