California Chiropractic
8501 Camino Media
Suite 200
Bakersfield, CA 93311
661-665-1800

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.

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Patient Information


Personal 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.)

   

How did you find out about our office?


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Employment Information


Insurance & Payment for Care


Primary Insurance
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Family Health History


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Social History & Life Choices:


 

Health Problems & Concerns:


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Authorization

TERMS OF ACCEPTANCE / INFORMED CONSENT In the course of chiropractic health care, it is essential for the physician and patient to work towards the same objective. As a patient, you should understand the goal and methods of Chiropractic that will be used in order to avoid confusion or disappointment. Segmental Dysfunction: Segmental dysfunction is aberrant motion of one or more articulating joint surfaces such that regional nerves are effected causing an alteration of their function by interfering with the normal transmission of mental impulses. This interference can impair the body’s ability to achieve maximum health potential. Adjustment: An adjustment is the specific application of forces to facilitate correction of the body’s segments that are in a state of dysfunction, either spinal or extremity. Our Chiropractic method of correction is by specific adjustments of the involved segments. Health: Health is a state of optimal physical, mental and social well being, not just the absence of infirmity. Benefits and Risks of Radiographic Studies: Benefits of Radiographic Studies include to rule out fracture, bone disease, certain cancers, degeneration, arthritis, soft tissue disease, lung diseases, to determine scoliosis, and proper alignment. Risks of Radiographic studies include a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. Radiation exposure to the fetus in pregnant women: Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. Benefits and Risks of Adjustments: Benefits of Chiropractic Adjustments include decrease pain, increased range of motion, decreased muscles spasm, decreased numbness, tingling, sharp, shooting, cramping, constricting, burning, dull, and achy sensations, increased energy, improved rest and sleeping, improved digestion, improved blood pressure, decreased allergies, decreased congestion, decreased anxiety, improved strength, and improved overall performance. Risks of Chiropractic Adjustments include: Temporary soreness or increased symptoms or pain. It is not uncommon for patients to experience temporary soreness or increased symptoms or pain after the first few treatments. In rare cases some may experience dizziness, nausea, or flushing during or after care. If you do it is important to notify your chiropractor. When patients have underlying conditions that weaken bones, like osteoporosis, they may be susceptible to fracture. It is important to notify your chiropractor if you have been diagnosed with a bone weakening disease or condition. If your chiropractor detects any such condition while you are under care, you will be informed and your treatment plan will be modified to minimize risk of fracture. Spinal disc conditions like disc bulges or disc herniation may worsen even with chiropractic care. It is important to notify your chiropractor if symptoms change or worsen. An extremely rare type of cerebral vascular occurrence has been associated by some with chiropractic care. It is important to note there is no concrete evidence of such occurrences. There is however an association between this type of vascular issue and primary care medical visits when medications are involved. Benefits and Risks of Massage and Manual Therapy: Benefits of massage include alleviate pain and improve range of motion, assist with shorter, easier labor for expectant mothers and shorten maternity hospital stays, ease medication dependence, enhance immunity by stimulating lymph flow—the body’s natural defense system, exercise and stretch weak, tight, or atrophied muscles, help athletes of any level prepare for, and recover from, strenuous workouts, improve the condition of the body’s largest organ—the skin, increase joint flexibility, lessen depression and anxiety, promote tissue regeneration, reducing scar tissue and stretch marks, pump oxygen and nutrients into tissues and vital organs, improving circulation, reduce post-surgical adhesions and swelling, reduce spasms and cramping, relax and soften injured, tired, and overused muscles, release endorphins—amino acids that work as the body’s natural painkiller. Risks of massage include unexplained pain or other symptoms, irritation and/or infection to burns or open wounds, the spread of cancer, formation blood clots, fractures in severely osteoporotic individuals, exacerbation of rheumatoid arthritis, premature labor, internal bleeding, temporary paralysis, and allergic reactions to massage oils or lotions. Benefits and Risks of Therapeutic Exercise: Benefits of Therapeutic Exercise includes reducing the risk of heart disease, developing and/or reducing diabetes, developing and/or reducing high blood pressure, reducing the risk of developing colon cancer, reducing feelings of depression and anxiety, helps control weight, helps build and maintain healthy bones, muscles, and joints, helps strength and endurance, helps balance and co-ordination, promotes psychological well-being. Risks of Therapeutic Exercise include dehydration, nausea, sprain/strains, fracture, heart attack, and stroke. We do not offer to diagnose or treat any disease of condition other than segmental dysfunction. However, if during the course of a Chiropractic examination we encounter Non-Chiropractic or unusual findings, we will recommend that you seek the services of a health care provider who specializes in the case. We do not offer advice regarding treatment prescribed by others. Our practice objective is to eliminate nerve interference. Our method is adjusting in effort correct segmental dysfunction. I have read or had read to me this informed consent document. I have discussed and/or been given the opportunity to discuss any questions or concerns with my chiropractor and have had these answered to my satisfaction prior to my signing this informed consent document. I have made my decision voluntarily and freely. PATIENT AUTHORIZATION It is the desire of this office to provide chiropractic care in an “open-door” and/or “open adjusting” environment. An “open-door” approach involves the doctor moving from patient care area to patient care area and leaving the doors between patient care areas open. “Open adjusting” involves several patients being seen in the same adjusting room at the same time. As a result patients are within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care and is NOT the environment used for taking patients histories, performing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting. It is our desire for our staff to use your name, address and/or telephone number for the purpose of contacting you to remind you about scheduled appointments, re-evaluations or other appointment related issues, contacting you to advise you about health related meetings, workshops, and products, thanking you for referrals, etc. We are requesting the authorization of you due to various interpretations under federal law with respect to what is known as an “incidental disclosures” of health information. It is our view that the kinds of matters related in an “open door”, “open adjusting” environments, appointment reminders are incidental matters, and in the event you or someone else would not agree with us we are providing this disclosure and requesting your authorization. The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care. You may revoke this authorization at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our procedures to be completed. Your signature indicates your authorization of these activities. PROFESSIONAL FEE SCHEDULE All fees are standard and based on professional association guide. Our experience has shown that it is best to have an understanding with our patients as to office policies and fees prior to initial evaluation. Therefore, this form has been prepared for your convenience and information. We offer several methods of payment for your Chiropractic Care at our office and you may choose the plan which best fits your needs. Please read carefully and to the plan which best fits your needs. This information will enable us to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well-being, and we will do our best to serve you. Plan #1 Insurance: If you have insurance which covers Chiropractic Care, as a courtesy to you, we will bill your insurance directly. Please understand that this is a courtesy and may be subject to change in the future. Please be sure to provide our office will all necessary information as well as a photocopy of your insurance card. If all necessary information is not provided or the information provided is inaccurate then you will be responsible for any and all charges incurred. Once we have verified insurance coverage we will discuss such coverage with you and inform you of your portion of financial responsibility. Please keep in mind that most all insurances have a deductible, copayments, and a percent that is not covered or any combination there of. Also understand that when an insurance company informs our office or even yourself of what the coverage is, that this “quoting of coverage” is “no guarantee of payment” as stated by the insurance companies. It is also important to know that insurance companies only cover “acute care” and do not cover “maintenance care”. Therefore, if your condition requires care beyond a reasonable time frame, which is determined by your condition and the cause of your condition, then your insurance may not cover such care. If this is the case with your condition, our office will discuss with you options to continue care in the absence of insurance coverage. Occasionally, depending on the insurance company, the check for your Chiropractic Care will go to you. If this occurs you are expected to bring the check to our office. Plan # 2 Cash: All fees are to be paid in full prior to the time of services. We do offer discounted plans if you pay for multiple visits in advance. Plan # 3 Industrial: Currently industrial injuries must be managed by your employer or your employer’s insurance company for one year following your injury. You will be required to see “in network doctors” chosen by your employer or your employer’s insurance company. Any services you are seeking from our office will need to be pre-authorized by the worker’s compensation insurance company and their network of doctors. Plan # 4 Auto/Personal Injury: We need you need to supply us with a copy of accident report, your car insurance, health insurance, the liable parties insurance, and attorney if applicable. Until necessary insurance information is gathered and verified for Chiropractic Care, you will be required to pay for your care. In the event you do not have Medical/Chiropractic coverage on your policy, “Med Pay” we will accept a portion of your care under an attorney lien and/or a third party lien. The other portion will require you to pay a monthly fee for care which will be deducted from your final bill. If you do have insurance coverage we will bill your insurance directly. In the event the check should come to you, you are expected to bring the check our office. Insurance Billing Policy: Our office will bill your insurance. You are responsible for the deductible, Share of cost, co-payment at the time of visit, and any costs not a benefit of your plan. Please note that our office requires payment at the time of your visit. Our staff is available if you have any questions. Consultations are at no charge. Chiropractic Examinations range from fifty to one hundred eighty-five dollars depending upon complexity and time. Chiropractic X-rays range from seventy-five dollars to four hundred twenty dollars depending upon regions and number of views. X-ray Interpretation is one hundred forty-five dollars. Regular Office Visits range from forty to one hundred ninety-five dollars depending on the services performed. “No Show”, 24 Hour Cancellation Notice and Late Arrival Policy: Our office reserves the right to charge forty-five dollars to the patient if the patient does not show up for the scheduled appointment. Our office also reserves the right to charge forty-five dollars to the patient if the patient does not cancel a scheduled appointment within 24 hours of said scheduled appointment. If the patient is more than five minutes late to a scheduled appointment, our office reserves the right to reschedule said appointment. By your signature below you are agreeing to the following: I authorize payment of medical benefits to be made directly to the physician provider services rendered. I authorize my Doctor to release any medical or other information necessary to process claims with my insurance companies. I request payment of any government (Medicare included) benefits to the party who accepts assignment. I authorize use of information from this form to bill my insurance companies.

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