Murray Natural Health & Chiropractic
1934 West 2nd Street
Hastings, NE 68901
(402) 463-4257
www.murraynaturalhealth.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.)

   

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.

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?

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.

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 hereby request and consent to the performance of chiropractic procedures, including various modes of physio therapy, diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures.I understand and I am informed that, as is with all Healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all Healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests.I further understand that Chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations allowing the body to return to improved health. It can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures. However, like all other health modalities, results are not guaranteed and there is no promise to cure. Accordingly, I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment.I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited self-administered, over the counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options.I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent to cover the entire course or treatment for my present condition and for any future conditions(s) for which I seek treatment.

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

Finalizing Form


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