Oahu Family Chiropractic
4747 Kilauea Ave
Suite 107
Honolulu, HI 96816
808-732-2244

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?

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Did you hear about our office from a phone or professional directory?

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Current Symptoms


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If Yes, Where?




Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Health Problems & Concerns:


Please select all that you have had or currently have.

Authorization

Informed Consent for Chiropractic Treatment and Care: I certify that I'm the patient or legal guardian listed above. I have read, or have had read to me, and 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 adjustments and other chiropractic procedures, including various modes of rehabilitation and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctors of chiropractic. I understand that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all of the risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time based on the facts then known, is in my best interests. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. The doctor will discuss any further risks inherent for my particular condition during a report of findings procedure. Any questions that I may have will also be addressed at this time.Insured: I hereby instruct the aforementioned insurance company to pay by check made out to and mailed directly to: Dr. Christopher or Dr. Shelley Kasprick, D.C. 4747 Kilauea Avenue, Suite 107 Honolulu, HI 96816 If my current policy prohibits direct payment to doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows: Dr. Chris or Shelley Kasprick , D.C. 4747 Kilauea Avenue, Suite 107 Honolulu, HI 96816For the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. This is a DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay in current manner any balance and/or CO-pay of said professional service charges over and above this insurance payment. I further understand that I will be responsible for payment to any other facilities and/or health care providers that I may be referred to by Dr. Chris and Shelley Kasprick and any emergency transporting that may be required thereto. I understand that fees or any balance on my account for professional services will become immediately due upon suspension or termination of my care or treatment. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in the case. Non-Insured: I hereby acknowledge that I have no insurance that covers chiropractic services, and I understand that all services are payable when treatment is rendered. I further understand that I will be responsible for payment to any other facilities and/or health care providers that I may be to by Dr. Chris and Shelley Kasprick and any emergency transporting that may be required thereto. By signing below, I agree to the named procedures and conditions.

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

Signature


Finalizing Form


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