Spinal Correction Center of Richmond
8536 Patterson Ave
Richmond, VA 23831
804-740-9300

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


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.

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:

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 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. ___________________________________________________________________ Consent for Purposes of Treatment, Payment and Healthcare Operations My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician. 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.I consent to the use or disclosure of my protected health information by Spinal Correction Center of Richmond PLLC for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Spinal Correction Center of Richmond PLLC. I understand that Dr. Mulvaney may refuse to diagnose or treat me, if I do not consent to the use or disclose of my protected health information for the above stated purposes. (My signature on this document is evidence of this consent.)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. Spinal Correction Center of Richmond PLLC is not required to agree to the restrictions that I may request. However, If Spinal Correction Center of Richmond PLLC agrees to a restriction that I request, the restriction is binding on Spinal Correction Center of Richmond PLLC and Dr. Mulvaney.I understand I have a right to review Spinal Correction Center of Richmond PLLC’s Notice of Privacy Practices prior to signing this document. Spinal Correction Center of Richmond PLLC Notice of Privacy Practices has been provided for me. The Notice of Privacy Practices describes the type of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Spinal Correction Center of Richmond PLLC. The Notice of Privacy Practices for Spinal Correction Center of Richmond PLLC is also provided on request at the main administrative desk of this practice. Notice of Privacy Practices also describes my rights and Spinal Correction Center of Richmond PLLC’s duties with respect to my protected health information.Spinal Correction Center of Richmond PLLC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling Spinal Correction Center of Richmond PLLC office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.I have the right to revoke this consent, in writing, at any time, except to the extent that Spinal Correction Center of Richmond PLLC or Dr. Mulvaney has taken action in reliance on this consent. _______________________________________________________________ Missed appointment policy: In order to give you and all our patients the best possible care, we request that you review our missed appointment policy. A missed appointment is when you fail to show up for an allotted appointment time, without a phone call or cancellation notice of at least 24-hours (one full business day). We have reserved appointment times especially for you and therefore kindly require at least 24-hours notice in order to reschedule your appointment and enable us to offer your cancelled appointment time to other patients. If you are unable to keep your scheduled appointment time, call our office at least 24-hours in advance (one full business day) in order to avoid a missed appointment fee. This charge is not covered by insurance. Your phone call is critical in helping us provide continuous care to all our valued patients. If you fail to give us notice of your missed appointment, you will be charged a $45 missed appointment fee.

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

Signature


Finalizing Form


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