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
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Contact Information
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(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.)
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Draw Your Symptoms
Click on a crayon and draw on the body above to indicate your symptoms
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
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Secondary Insurance
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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.
Personal Incident History:
Family Health History
Separate details with "," comma as shown above.
(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol,
etc.)
Social History & Life Choices:
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.
Were You Aware That...
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 understand that chiropractic care, spinal decompression and K-Laser, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with chiropractic care, spinal decompression, and K-Laser. The types of complications that have been reported secondary to chiropractic care, spinal decompression, and K-Laser include sprain/strain injuries, irritation of a disc condition, and rarely, fracture. One of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral artery injury that could lead to stroke.Prior to receiving chiropractic care, spinal decompression, and/or K-Laser at Balance Chiropractic Clinics, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spine health. These procedures will assist us in determining if chiropractic care, spinal decompression, and K-Laser is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care. I hereby authorize the doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. I understand and accept that there are risks associated with chiropractic care, spinal decompression and K-Laser, and give my consent to the examinations that the doctor deems necessary, as reported following my assessment. The doctor will not be held responsible for any per-existing medically diagnosed conditions nor for any medical diagnosis. 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 payment of such services at time of service. 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 are due at time of service. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider for services rendered.
Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature