F.I.T Muscle & Joint Clinic - Shawnee
22120 Midland Drive, Set 1
Shawnee, KS 66226
913-745-4064
https://www.fitmjc.com

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

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:


 

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.

Authorization

INFORMED CONSENTMedical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required by law to obtain your informed consent before starting treatment. I do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Physical therapy and exercises may also be used. Although spinal and extremity manipulations/adjustments is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware there are possible risks and complications associated with these procedures as follows:Soreness/Bruising: I am aware that like exercise it is common to experience muscle soreness and occasionally bruising in the first few treatments.Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare.Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities, or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution.Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke is reported to occur once in ten million treatments. Once in a million is about the same chance as getting hit by lightning. Once in ten million is about the same chance as a normal dose of aspirin or Tylenol causing death. Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase in pain and possible blistering. This should be reported to the doctor. Tests have been or will be performed on me to minimize the risk of my complication from treatment and I freely assume these risks. TREATMENT RESULTSI also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility, function, and reduced muscle spasm. However, I acknowledge there is no certainty that I will achieve these benefits. I realize that the practice of medicine, including chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the performance of these procedures by my doctor and such other persons of the doctor’s choosing. ALTERNATIVE TREATMENTS AVAILABLEReasonable alternatives to these procedures have been explained to me including, rest, home applications of therapy, prescription or over-the-counter medications, exercises, and possible surgery.Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side effects, physical or psychological dependence, and may have to be confirmed indefinitely. Some medications may involve serious risks. Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily, reduce inflammation and pain. The same is true of ice, heat, or other home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Exercises are of limited value but are not corrective of injured nerve and joint tissues. Surgery: Surgery may be necessary for joint instability or serious dis rupture. Surgical risks may include unsuccessful outcome, complications, pain, or reaction to anesthesia, and prolonged recovery.Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthy. I have read or had read to me the above explanation of chiropractic treatment. Any questions I have regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely. Financial/Privacy Policy and DisclaimerInsurance Verification Insurance verification is not a guarantee of payment. Verification is only a quote of patient benefits. Insurance companies review charges individually and make payment accordingly. Charges not covered by insurance are the patient’s responsibility and due within 30 days of billing. Deductible Payments It is our policy to collect at time of service. Once we receive an “Explanation of Benefits” report form the patient’s insurance company, we will bill or credit the account for the remaining balance. Reimbursement checks can be issued upon request. Collection of Patient Balance Co-payments and Co-insurance is the patient’s responsibility and will be collected at the time of service. If an “Explanation of Benefits” of EOB shows the patient has an outstanding responsibility for any reason, the patient will receive a bill outlining the outstanding charges. Payment is due within 30 days of receipt of the bill. In the event a bill is disputed, you must notify use within 30 days. If you do not notify us within that time, the bill will be presumed valid and due. In the event any further action is necessary to collect an unpaid bill, you will be responsible for all attorney’s fees and court costs incurred by us. All balances remaining unpaid after 30 days may be turned over to a collection agency.Returned Checks It is our policy to collect $25.00 for checks that are returned to us. This is to cover any fees that apply from the transaction. Appointments If unable to keep an appointment, as a courtesy to our staff and other patients please give 24-hour notice.Financial Policy Questions We are happy to address questions regarding your account at any time. Please direct accounting questions to our billing administrator(s) Chad Barnes or Matthew Lane.HIPAA Privacy Policy Attached to the patient information packet at the back of these forms is the HIPAA Notice of Privacy Practices Policy for you. By signing below, the patient acknowledges that he/she has received the HIPAA Privacy Policy and that he/she understands and will comply with our financial policies. Designation of Authorized Representative I do hereby designate F.I.T. Muscle & Joint Clinic to the full extent permissible under the Employee Retirement income Security Act of 1974 (“ERISA”) and as provided in 29 €FR 2560-503-1(b)4 to otherwise act on my behalf to pursue claims and exercise all rights connected with my employee health care benefit plan, with respect to any medical or other health care expense(s) incurred as a result of the services I receive from F.I.T. Muscle & Joint Clinic. These rights include the right to act on my be-half with respect to initial determinations of claims, to pursue appeals of benefit determinations under the plan, to obtain records, and to claim on my behalf such medical or other health care service benefits, insurance or health care benefit plan reimbursement and to pursue any other applicable remedies. IRREVOCABLE Power of Attorney I do hereby authorize F.I.T. Muscle & Joint Clinic act on my behalf to pursue claims and exercise all rights in order to collect insurance payments with respect to any medical or other health care expense(s) incurred as a result of the services I receive from F.I.T. Muscle & Joint Clinic. Appointments: If you are unable to keep an appointment, as a courtesy to our staff and other patients, please give 24 hours notice. Patients who cancel with less than 24 hours notice will be charged a $30.00 “Late Cancellation Fee.” Patients who do not show up for an appointment and do not call to cancel that appointment (“No Call, No Show”) will be charged a No Call, No Show/Cancellation fee of $55.00. The patient will be responsible for payment. In addition, cancellations and “No Call, No Show” for appointments made outside of normal clinic hours will be charged full “Time of Service” fee.By clicking "SUBMIT" you are hereby ELECTRONICALLY SIGNING this authorization form and acknowledge all information/statements contained within.

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

Signature


Finalizing Form


  1. Submit Form!