Delta Spinal Chiropractic, LLC
11720 Old Ballas Rd.
Suite B
Creve Coeur, MO 63141
314-725-3358

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


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:


 

For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

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 Herby assign payment of authorized medical benefits including, but not limited to, major medical benefits and property and casualty insurance benefits, to which I am entitled, to be made on my behalf to Delta Spinal Care ( hereafter “facility”) for any services furnished me by their practitioners. I fully authorize the staff and doctors of Dela Spinal Care to perform any examinations, diagnostic tests and/or treatments as they may consider medically necessary. I understand there are no guarantees or promises of improvement or complete recovery. I authorize release of any and all medical information needed to determine these benefits payable to related services. I understand that I am financially responsible for all charges and/or interest accrued due to unpaid balances as per Delta Spinal Care’s policies, whether or not paid by said insurance. I authorize the performance of Chiropractic Care, as described to me, on myself which the doctors of Delta Specific Chiropractic or their associates may consider necessary or advisable.I authorize the performance of diagnostic x-ray examination of myself which the doctors of Delta Specific Chiropractic or their associates may consider necessary or advisable in the course of my examination or adjustments. This also certifies that to the best of my knowledge I am not pregnant and the doctors of Delta Specific Chiropractic or their associates have permission to perform diagnostic x-ray examination. I have been advised that x-ray can be harmful to an unborn child.Delta Spinal Care does not deny any benefits or services because of race, color, national origin, age gender, disability, religious or political beliefs. If you feel you have been discriminated against, you may file a complaint of discrimination with the manager of this facility. You will not suffer any penalty because you file a complaint. HIPPA requires that we have you read and sign the federally governed health care privacy notice. The health care privacy notice will explain when, where and why your confidential health information may be used, stored, and/or shared and is a part of your permanent medical records which are maintained in this office. You may receive a free photocopy of this document that you have signed just by asking one of our staff. Patients are encouraged to leave valuables at home or with a family member or friend. This facility shall not be liable for the loss of or damage to any personal property including but not limited to money, Credit cards, clothing, jewelry, glasses, contacts, dental devices, hearing aids, furs, documents or any other items. In addition, I agree to pay any additional charges related to the cost of collection (including but not limited to, collection agency fees, reasonable attorney fees and court costs) in the event that I would fail to pay my bill. I understand that if I fail to make any scheduled appointment, without first contacting delta spinal care, I will be charges a $15 missed appointment fee which I must pay before I am seen or treated again by a doctor or staff member. I authorize the staff and/or doctors of Delta Spinal Care to call me on the telephone and/or mail/email a reminder when an appointment is missed or I have not been in contact with the facility to reschedule an appointment. If I do not wish the staff and/or doctors to call or mail me a reminder I will notify Delta Spinal Care in writing. My signature on this document confirms that I have read, understand, and agree to comply with all of the terms and conditions of the health care privacy notice and all policies, consents, terms and conditions regarding my responsibility to this facility and that I grant the staff, therapists, and the doctors of this facility to use and share my confidential health information with others in order to treat me and/or in order to arrange for payment of my bill and/or for issues that concern this facilities operations and responsibilities. I will direct all questions concerning this or other documents and polices to the staff of Delta Spinal Care which encourages questions to avoid misunderstandings.

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

Finalizing Form


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