Accident & Sports Injury Clinic
201 Harding Blvd
Suite J
Roseville, CA 95678
916-784-2727

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:

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

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.

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:





Results:

Health Problems & Concerns:


Please select all that you have had or currently have.

Worker's Compensation







Describe the accident?

Do you lift from?

Do you have to reach?
Is your work area cluttered?
Do you push or pull?
Do you pick up or lift?

Do you lift in and out of a machine?
Type of Floor:

Type of ventilation:

Type of lighting:

Is your work area:

Do you have any other jobs?
Has outside help been hired?
Do you use a cart?



Auto Accident










Visited a Hospital or Doctor?






Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

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/acupuncture. 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. This office will bill my insurance as a courtesy to me, however I will be responsible for all co-pays and deductibles at the time of service and the entire bill and any costs incurred for the collection of this account if my benefits are not covered or have been denied. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. PRIVACY CONFIDENTIALITY STATEMENTTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.DISCLOSURE OF INFORMATIONWe may disclose information to other healthcare professionals and/or your Insurance carrier for treatment, payment or healthcare operations. Additional disclosures may be necessary to comply with Workers’ Compensation and Public Health Laws as well as Judicial proceedings. We may contact a family member or other authorized person in the event of an emergency. Be assured that we will not disclose any information without your expressed written consent unless compelled to do so by legal authority.Missed appointmentsIt is our policy to call your home or office when an appointment is missed. If you are not at home, we will leave a message on your answering machine or with the person answering the phone. We will not leave any message that discloses confidential information. If you would like to use an alternate contact number, please inform us of the number you would prefer.MailingsIt is our policy to send a birthday postcard on or near the date of a patient’s birthday. We also send reminder cards and thank-you cards to patients. If you would prefer that we discontinue mailings to your home please inform a member of the staff and your name will be removed from future mailings.Facility set upWhile our examination and treatment rooms are private, this office utilizes an open exercise/rehabilitation/therapy setting. The staff and doctors will maintain policies to ensure privacy, but there may be some inadvertent disclosure to others in the facility at the same time. If there is private information that you need discussed, please request to have such discussions in a private room.Your Rights•Send us a written request to see or procure a copy of the information that we have about or amend your personal information that you believe is incomplete or inaccurate. If we did not create the information, we will refer you to the source of the information, such as other doctors or hospitals.•Request additional restrictions on uses and disclosures of your health information. We are not required to agree to these requests and in some instances they may be prohibited by law.•Request that we communicate with you about medical matters using reasonable alternative means or at an alternative address.•Receive an accounting of our disclosures of your medical information, except when those disclosures are made for treatment, payment or healthcare operation, or the law otherwise restricts the accounting.•You have the right to inspect and have a copy of your health information. There will be a fee for this service.•You have the right to amend your information. Please note that we have the right to disagree with your amendments. If there is a disagreement, you will be provided with information about our denial of your amendment and how you may appeal the denial of the amendment.•You have the right to a copy of this notice upon request.ComplaintsComplaints about your privacy rights or how your privacy is handled at this office can be directed to Scott Owens by calling this office or directing a letter to her attention. If you are not satisfied with how this office handles your complaint, you may submit a formal complaint to: DHHS (Office of Civil Rights) 200 Independence Ave, S.W. Room 509F HHH Building Washington, D.C. 20201I have read this Privacy Notice and understand my rights contained in this notice. By signing this form, I provide authorization and consent to use and disclose my protected health information as noted above.

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

Signature


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