Harris Meyer, D.C.
100 Bush St.
Suite 530
San Francisco, CA 94104
415-956-3226

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.)

   

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

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.

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:

Health Problems & Concerns:


Please select all that you have had or currently have.

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 am the patient or legal guardian listed above. I have read and understand the included information and attest to its truth and accuracy. I consent to the collection and use of the above information by this office and I authorize this office and its staff to examine and treat my condition as the doctor sees fit. I hereby authorize the doctor to release all information required by any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred for my care/case management. 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 me, not Dr. Meyer’s office. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. Notice of Privacy Practices (HIPAA): I consent to the use or disclosure of my protected health information (PHI) by Dr. Meyer’s office for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations. I understand that analysis, diagnosis, or treatment of me by this office may be conditioned upon my consent as evidence 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. Dr. Meyer is not required to agree to the restrictions that I may request. However, if he agrees to a restriction that I request, the restriction is binding on him. I have the right to revoke this consent, in writing, at any time, except to the extent that this office has taken action in reliance on this consent. My PHI means health information, past of present 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. I have been provided with access to a copy of the Notice of Privacy Practices of this office and understand that I have a right to that 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 this office. The Notice of Privacy Practices for this office can also be found in the waiting room at 100 Bush St., Ste. 530, San Francisco and on the web site. This Notice of Privacy Practices also describes my rights and duties of this office with respect to my PHI. This office 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 office and requesting a revised copy be sent in mail or asking for one at the time of my next appointment.

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

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