Health-Plus ATX
3939 Bee Caves Rd., Ste. 203A
Suite A203
West Lake Hills, TX 78746
512-524-5292

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

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.

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Family Health History


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(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Social History & Life Choices:


 

Chiropractic Experience

Please select all that apply.

Other:

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:





Results:

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.

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 understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. We DISCLOSURE OF FEES PAYMENT POLICY New Patient Evaluation-Detailed $185; Office Visit Appointment $85; Laboratory Fees are dependent on the tests that are medically necessary. I have read the above fees and understand the cost of my care with my treating doctor. I understand that I am responsible for full payment at the time of service. I further understand that my insurance is a contract between my insurance provider and myself and that this office does not accept assignment of benefits. I have read and fully understand the above financial terms and prices.CONSENT TO CARE/INFORMED CONSENT. A patient coming to the doctor gives him/her permission and authority to care for the patient in accordance with appropriate tests, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases underlying physical defects, deformities or pathologies, may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities which would otherwise not come to the attention of the physician. With the nature or chiropractic care it possible but unlikely that the patient may experience side effects from treatment. Such side effects include but are not limited to soreness/stiffness, bruising, dizziness, fracture and potentially stroke. If the patient experiences any symptom they consider a side effect from the treatment they are to report this to the doctor immediately as it may be an indication of an underlying pathology. I have read and understand the foregoing and consent to treatment. PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE I hereby acknowledge receipt of the Notice of HIPPA Privacy Practices for Health-Plus regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting Dr. Noah J Moos of our clinic at (512) 524-5292 Health-Plus 3939 Bee Caves Building A Suite 203A Austin, TX 78746My signature herein below constitutes full acknowledgement that I have furnished a copy of the Notice of Privacy Practices for Health-Plus.

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

Signature


Finalizing Form


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