Jones Chiropractic Center P.C.
2215 Jordan Ave
Juneau, AK 99801
(907)500-4888
akchiros@gmail.com
www.alaskachiros.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.)

   

Complaint Information


If you have more than one complaint, address your primary complaint in your responses to the questions in this section and select Yes to indicate that you have an additional complaint. The form will populate a secondary question section for you to address your additional complaint. You may address up to four complaints.

What is the purpose of your visit?
What is the reason for this visit?
Date of scheduled appointment
When did this condition begin?
How long have you had this condition?
What caused this condition?
Where is the discomfort?

Select only one area of discomfort for your chief complaint. Add additional areas of discomfort as additional complaints by selecting Yes in response to Do you have an additional complaint? at the bottom of this section.

Head

Neck

Back


Trunk

Upper Extremity






Lower Extremity





Does the discomfort radiate/travel?
Describe the quality of the discomfort. Choose all that apply.
Describe the onset of the discomfort. Choose only one.
Describe the intensity of the discomfort. Choose only one.
Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.
Least severe <----------------------------> Most severe
How often do you feel this discomfort? Choose only one.
How has this complaint changed since the onset?
What activity is most significantly affected by this discomfort?
What aggravates this condition? Choose all that apply.
What improves this condition? Choose all that apply.
What treatment have you received for this condition up to now?
Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?
Have you ever had any previous episodes of this condition?
In what ways does this condition affect your life and your ability to function? Choose all that apply.
Do you have an additional complaint?

Review of Systems


Musculoskeletal

Neurological

Head, Eyes, Ears, Nose and Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Endocrine

Dermatological and Bleeding

Past, Family and Social History


List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.
Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred. Respond respectively to each illness listed. If personal health history is good, select "No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)"





List any past history of accidents or trauma. Choose all that apply.
Are you presently taking any medication?
List your (or the patient's) family health history. Choose all that apply to blood relatives only.
What are your (or are the patient's) current work habits? Choose all that apply.



How would you describe your (or the patient's) personal social habits? Choose all that apply.




How would you describe your (or the patient's) present exercise habits? Choose all that apply.
How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.

Standard Pediatric Evaluation


Is there a history of any problems that the doctor should know about? Choose all that apply.
How was the baby delivered?
Were forceps used in the delivery process?
Was vacuum extraction used in the delivery process?
How many hours was the labor?
How long was the pushing (in minutes)?
Was this a single or multiple birth?
What was the birth weight (pounds)?
lbs.
What was the birth weight (ounces)?
oz.
What was the length of the child at birth (inches)?
inches in length
What was the total APGAR score (5 minutes after birth, 10 is perfect)?
At how many weeks was the child born (gestational age in weeks)?
 weeks
Which vaccines has the child had to date? Choose all that apply. If all vaccination are up to date, select "Received all childhood vaccinations."

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.

Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.




Authorization

PATIENT FINANCIAL RESPONSIBILITY This office will provide insurance billing services for you, if you so desire, as a courtesy. Remember that you are ultimately responsible for any charges incurred in this office. It is your legal responsibility to pay any deductible amount, co-insurance, and or any other balances not paid by your insurance carrier. Your signature on this document indicates that you agree to pay for any outstanding charges incurred in this office. Patients who do not have health insurance: since we will not need to pay staff to bill and follow up with insurance companies, we pass the savings on to you. We offer EVERYONE our Time of Service rates when their accounts are paid in full on each visit. Unclaimed credits will be forfeit after 2 years. Patients with a deductible have two options:1. You can pay our regular fee schedule and we will bill insurance for you. This notifies the insurance company that your deductible should be reduced by what you pay on each visit. If and when the deductible is met, your plan will most likely switch to a co-pay status.2. You can pay our Time of Service fees, which are significantly less than our regular fees. However, you will then be responsible for submitting all services you have paid for to your insurance for reimbursement. We will not be billing on your behalf. Please pay any deductible or copay amounts at the time of service. We will strive to work out feasible payment options for anyone who is in need of care. Unless other prior written agreements have been made, any outstanding balance more than 60 days old is considered delinquent. A re-billing fee of 2 % (based on the outstanding balance, per month) will also be added to all accounts that fit this criterion. Office policy dictates that delinquent accounts may be referred to Cornerstone Credit Services for collection which may include possible blemishes on your credit record. If this happens, an administrative collection fee of 30% may be added to your account to cover our costs and you specifically authorize us to run your credit report. If your insurance denies payment for any reason, we will offer you our time of service discount (our lowest fee schedule) for any outstanding charges that are paid in full within 15 days of notice. I authorize payment of insurance benefits directly to Jones Chiropractic P.C. I also authorize the doctor to release all information necessary to communicate with personal physicians, other healthcare providers, collection agencies, and payers to secure the payment of benefits or inform them of concurrent treatment. By signing below, I indicate that I have read, understand, and agree with the terms on this page. Consent for Purposes of Treatment, Payment & Healthcare Operations HIPAA Notice I consent to the use or disclosure of my protected health information by Jones Chiropractic Center P.C. for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Jones Chiropractic Center P.C. I understand that analysis, diagnosis or treatment of me by Jones Chiropractic Center P.C may be conditioned upon my consent as evidenced by my signature below. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. If I request a restriction, Jones Chiropractic Center P.C may or may not agree to a restriction that I request, the restriction is binding on Jones Chiropractic Center P.C. I have the right to revoke this consent, in writing, at any time, except to the extent that Jones Chiropractic Center P.C has taken action in reliance on this Consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. The privacy practices of Jones Chiropractic Center P.C are as follows; our patients’ documents will not be released outside of our office without express agreement from the patient. The documents that can be released with permission from the patient are for purposes of treatment and billing compliance with an insurance company. Any request for the release of records must be signed in witness of a Jones Chiropractic Center P.C employee. Each employee at Jones Chiropractic Center P.C is informed on HIPAA laws and regulations. Jones Chiropractic Center P.C reserves the right to change the privacy practices that are described above. I may obtain a revised notice of privacy practices by calling the office of Jones Chiropractic Center P.C and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. Informed Consent to Chiropractic Care Chiropractic Adjustment: The doctor will use his/her hands or a mechanical device in order to adjust your spinal joints. This procedure is called a spinal adjustment and is intended to reduce spinal subluxation (slight dislocation of the spinal joints). You may feel a ‘click’ or a ‘pop’ as well as a movement of the joint. Various ancillary procedures such as, support pillows, cold laser, traction or hot/cold packs may also be used. Risks: As with any health care procedure, complications are possible following a chiropractic adjustment. Fracture of bone, muscular strain, ligament strain, dislocation of joints, injury to intervertebral discs, nerves or spinal cord are all rare occurrences and generally result from some underlying weakness of the bone or surrounding tissues. Usually, there is an underlying, pre-existing vascular condition like atherosclerosis that contributes in a stroke resulting after a neck adjustment. A minority of patients may notice stiffness or soreness after the first few days of treatment. We will not accept individuals for treatment unless we feel confident that we can safely help them. Probability of Risks: The risks and complications of chiropractic care, acupuncture and massage have all been described as ‘rare’. The risk of cerebrovascular injury or stroke has been estimated at one in one million to one in twenty million, and can be even further reduced by our screening procedures. The probability of adverse reaction due to ancillary procedures is also considered to be ‘rare’. Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult. I have had the following risks of my case explained to me. If you/and/or the individual listed below understand the above information, please sign below. This signature authorizes treatment, acknowledges Notice of Privacy Practices and also authorization to submit to insurances (if applicable). Patient or guardian understands that he/she is responsible for payment of all services. Patient Authorization: I have read or have had read to me, the explanation of care offered at this facility. I have had the opportunity to have any questions answered. I have fully evaluated the risks and benefits of undergoing treatment and hereby give my full consent to the items mentioned above. Massage clients that would like medical massage billed to your insurance please read and complete the following: You must have a valid doctor’s prescription for medical massage therapy. Dr. Jones can write prescriptions for her patients whose care she feels would be augmented by medical massage. Massage prescriptions do not supersede insurance benefits and/or coverage and policy limits. You are responsible for knowing your insurance policy coverage and limits for medical massage. We would be happy to verify benefits for you if you aren’t sure but this must be done and confirmed prior to scheduling your appointment. Jones Chiropractic Center will bill the charges to your insurance (primary and secondary if applicable) but you are ultimately responsible for any and all deductibles, copayments, services scheduled outside of your prescription and/or benefits and those services that are denied for any reason. All copays, deductibles and coinsurance are due at the time of service. Please be prepared for this. All appointments not given 24 hour cancellation notice will be subject to a $75 no show fee. I have read and understand the above and authorize these services and care.

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

Signature


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