Round Rock Chiropractic
301 Hesters Crossing
Suite 212
Round Rock, TX 78681
512-388-3880

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.)

   

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




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.



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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?

Family Health History


Separate details with "," comma as shown above.

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

Reason for this Visit

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

Does this concern interfere with:





Results:

Health Problems & Concerns:


Please select all that you have had or currently have.

Authorization

CONSENT TO TREATMENT Health care providers are required to advise patients of the nature of the treatment to be provided, the risks and benefits of the treatment, and any alternatives to the treatment. There are some risks that may be associated with treatment, in particular you should note: • While rare, some patients have experienced rib fractures or muscle and ligament sprains or strains following treatment. • There have been rare reported cases of disc injuries following cervical and lumbar spinal adjustments although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal or soft tissue manipulation or treatment. • There have been reported cases of injury to a vertebral artery following osseous spinal manipulation. Vertebral artery injuries have been known to cause a stroke, sometimes with serious neurological impairment, and may, on rare occasions, result in paralysis or death. The possibility of such injuries resulting from cervical spine manipulation is extremely remote. Osseous and soft tissue manipulation has been the subject of government reports and multi-disciplinary studies conducted over many years and have demonstrated it to be highly effective treatment of spinal conditions including general pain and loss of mobility, headaches, and other related symptoms. Musculoskeletal care contributes to your overall well being. The risk of injuries or complications from treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms. I acknowledge I have discussed the following with my healthcare provider: 1. The condition that the treatment is to address; 2. The nature of the treatment; 3. The risks and benefits of that treatment; and 4. Any alternatives to that treatment. I have had the opportunity to ask questions and receive answers regarding the treatment. ASSIGNMENT OF BENEFITS The professional of 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 RIGHT AND BENEFITS UNDER THIS POLICY. This payment will not exceed my in indebtedness to the above-mentioned assignee, and I have agreed to pay in current manner, any balance of said professional service charge over and above this insurance payment or any balance my insurance does not reimburse. I grant Round Rock Chiropractic special power of attorney to endorse drafts, checks, and money orders paid on my behalf from any third party including but not limited to the above-mentioned insurance company. A photocopy of this Assignment shall be considered effective and valid as the original. Release of Information I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. OUR OFFICE POLICY REGARDING YOUR INSURANCE Our office is pleased to accept your insurance assignment as soon as your exact coverage is verified by the responsible party. We will file your claim forms and assist you in every way we can. However, it must be fully understood that the contract is between you and your insurance company and you are fully responsible for any amount not paid by your insurance company. Below is a list of our office policies regarding your insurance. Please take the time to read carefully and understand our policies. We will happily answer any questions you may have, then, please sign and date the bottom. • Since by taking your insurance on assignment, we have to wait for payment. This is a courtesy that may be withdrawn if circumstances warrant. • If you discontinue care without your doctor’s advisement, the balance of your account is due and payable in full immediately, even if your insurance has already been filed. • Your insurance should pay within 60 days. If your insurance has not paid within 90 days, you must pay minimum of $50 per month until your balance is paid in full, or until your insurance pays. You may keep a credit card on file for convenience for monthly payments. • The co-pay amount or the percentage that is the patient’s responsibility is due when services are rendered. If you cannot afford this, you may set up a monthly payment plan that is agreed upon by you and the office manager. For your convenience, we have several payment options available to you upon request. • You are required to sign an “Assignment of Benefits” form and any other documents required by your insurance company on your first visit. • Our office does NOT guarantee that your insurance will pay. We will make every attempt to verify benefits of your policy and what it covers. However, if your insurance claim is denied, you are responsible for the full amount of your bill. • Our office will NOT enter into a dispute with your insurance company over your claim. This is your responsibility and obligation. • All special arrangements regarding finances must be signed off by the office manager. • We reserve the right to charge for any appointment or service not cancelled within 24 hours of the scheduled appointment time. • We DO NOT accept Third Party Claims WITHOUT an attorney. In any case associated to an accident, we only accept Your Personal Injury Protection, Your Major Medical Insurance or Cash/Credit Cards. PLEASE REVIEW THE NEW HIPAA POLICY EFFECTIVE 9/20/13 ON OUR WEB-SITE WWW. ROUNDROCKCHIRO.COM OR ASK TO REVIEW A COPY AT OUR FRONT OFFICE

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

Signature


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