The Movement Fix
19031 33rd Ave West, Suite 315
Lynnwood, WA 98036
425-405-4554

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?




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.

Family Health History


Separate details with "," comma as shown above.

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

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.




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

---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 grant the use of my signed statement of authorization with my signature for required insurance submissions. 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. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.---FINANCIAL POLICY---: -*Private Insurance*- We will be glad to submit claims to your primary and secondary insurance carrier(s). Most insurance companies pay a portion of each visit and/or have a deductible to satisfy before claims will be paid. Some of the insurance companies only pay for some of the services that you may receive at this office, such as spinal adjustments. If the insurance company does not pay for services such as traction, massage, extremity adjustments,hot/cold packs, exercise rehabilitation or others, these services become your responsibility. Your insurance contract is between you and your insurance company. You are responsible for any amount the insurance company does not pay. A $15 monthly late fee will be added to balances past 60 days.-*Work-Related Injury*-If your visit is consistent with an on-the-job injury, please let us know. If your claim is accepted, your chiropractic visits are covered at 100%. In the event of a rejected claim, you will be responsible for the charges incurred. A $15 monthly late fee will be added to balances past 60 days. -*Personal Injury*-If your injuries resulted from a motor vehicle accident or other personal injury, the claim number and insurance/attorney information will be needed. If your claim does not result in a settlement paid by the insurance company, the charges then become you responsibility. A $15 monthly late fee will be added to balances past 60 days. ---MISSED APPOINTMENT POLICY---: If you need to change or cancel and appointment, you must do it 24 hours in advance. If you change or cancel without 24 hours prior notice, there will be a $40 late cancellation fee. ---ACKNOWLEDGEMENT OF PRIVACY PRACTICES---: This notice summarizes how health data about you may be used and shared and how you can get access to this data. IMPORTANT NOTE: This does not include all of the details about our privacy policy. For further details, please ask to seethe NOTICE OF PRIVACY PRACTICES. I. How we may use and share health data about you: a) Treatment - To give you medical treatment or other types of health services. b) Payment - To bill you or a third party for payment for services provided to you. c) Health Care Operations - For our own operations such as quality control, compliance monitoring, audit, etc. II. Disclosures where we do not have to give you a chance to agree or object: a) To you b) As required by federal, state, or local law c) If child abuse or neglect is suspected d) Public health risks (for public health activities to prevent and control spread of disease) e) Lawsuits and disputes (in response to a court or administrative order) f) Law enforcement (to help law enforcement officials respond to criminal activities) g) Coroners, medical examiners and funeral directors h) Organ or tissue donation facilities if you are an organ donor i) To avert a threat to an individual or to public health safety III. Disclosures where we have to give you a chance to agree or object:a) Patient directories - You can decide what health data, if any, you want to be listed in patient directories.b) Persons involved in your care or payment for your care - We may share your health data with a family member, a close friend, or other person that you have named as being involved with your health care.IV. Other uses of health data: Other uses not covered by this notice or the laws that apply to us will be made only with your written consent.V. You have the following rights relating to the health data we keep about you:a) Right to inspect your health record and to receive a copy of your health record upon request b) Right to amend information in your health record you believe is inaccurate or incomplete c) Right to know to whom we have disclosed your health information d) Right to ask for limits on the health information data we give out about you e) Right to receive communication from us about your health information in alternate ways f) Right to a paper copy of the complete Notice of Privacy Practices I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice, or one has been made available to me.

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

Signature


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