Chiro-Works
1019 West Galena Ave.
Freeport, IL 61032
815-232-2225

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?




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.)

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

Certification and 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. Authorization of Payment:I hereby guarantee full payment for all services rendered to me by Chiro-Works. I understand and agree that health insurance policies, accident insurance policies, personal injury claims, and any other third party pay arrangements are between the third party and me. I understand that Chiro-Works will assist me in preparing the necessary reports and forms to enable me to make collection from insurance companies and other third parties. I will authorize and direct third parties to make payments directly to Chiro-Works, said payments will be credited to my account upon receipt. I understand that all services rendered to me are my responsibility and I guarantee the payment thereof. I agree that my account shall be payable in full upon the completion (by settlement or trial) of any personal injury claim. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.In the event of a default under the terms of this Agreement, I understand that Chiro-Works may accelerate the full balance due for my treatment. In the event of a default, I agree to be responsible for any attorney’s fees and costs incurred by Chiro-Works to collect the balance due on my account. In the event of a default under the terms of this Agreement, I agree to pay 1.5% interest per month (18% per annum) on the unpaid balance. I understand that in the event I fail to make any payment as required by this Agreement that I will be in default. I authorize my attorney and any insurance company involved in my claim to make direct payment to Chiro-Works for payment on my account.

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

Signature


Finalizing Form


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