Casper Mountain Chiropractic
5850 E 2nd St
Casper WY 82609
307-473-1000

Please Answer ALL Questions
**********WHEN TYPING IN DATES YOU MIGHT NEED TO ENTER THE YEAR FIRST***********If it is not auto related or an accident at work skip those sections***

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.

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.)

Social History & Life Choices:


 

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:

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. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for payment which is due at time of service. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself and benefits quoted are not a guarantee of payment. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.I, the undersigned patient/guardian, agree that in the event of non-payment to Casper Mountain Chiropractic (CMC) of any amounts due under this agreement I will pay interest thereon at the rate 1.75% per month and pay all of CMC's reasonable legal fees and court costs that may be incurred. I agree that in the event this account is assigned to a collection agency I will pay 35% of the unpaid balance due which is in addition to the unpaid balance. I also agree to pay $45.00 in the event that I do not show up for an appointment that I have not called to cancel.WYOMING MEDICAID (T-19) PATIENTS:Medicaid patients 21 years of age and older have a $2.45 co pay for each visit for medically necessary charges.Should Wyoming Medicaid determine the charges are NOT medically necessary you will be billed for the entire balance.In the event that you don't show for an appointment and don't call to cancel you will be charged $45.00.

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

Finalizing Form


  1. Submit Form!