Vanderhoof Sports & Wellness Institute
616 University Ave
Palo Alto, CA 94301
650-323-6184

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.

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Patient Information


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(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

Authorization

OFFICE POLICIES: 1.24 HOUR CANCELLATION. Vanderhoof Sports and Wellness Institute (VSWI) requires 24 hour cancellation notice for each chiropractic/massage appointment scheduled. If less than 24 hours is given, you will be charged $40 for chiropractic and FULL rate for massage. If we are able to fill your scheduled appointment then no charge will be applied. 2.RELEASE OF INFORMATION. To the extent necessary to determine responsibility for payment and to obtain reimbursement, VSWI may disclose pertinent portions of your financial or medical record to insurance companies, health care services plans, worker’s compensation carriers, corporations, lawyers, billing service, or persons who are or may be responsible for all or any portion of your account. Your information may also be released to the referring physician and other health facilities to ensure continuity of care. VSWI will obtain your consent and written authorization to release information, other than basic information, concerning your patient file, except in those circumstances when VSWI is permitted or required by law to release information. 3.FINANCIAL AGREEMENT. I understand and agree that ALL fees for service provided, including those fees not fully paid and/or covered by insurance programs, are due and payable at the time of service. Except any portion exempted pursuant to an agreement between the insurance provider and medical service provider. I understand and agree that I have complete financial responsibility to VSWI for all medical services provided and this financial responsibility is not contingent upon my obtaining settlement or any other financial payment. In consideration of the chiropractic services to be rendered, you or the patient’s guarantor signing on the patient’s behalf hereby agree to accept FULL financial responsibility for your account with the rates and terms of any contracts between VSWI, you and the insurance company if VSWI contracts with the insurance company, or in accordance with regular VSWI rates and terms. Should the account go to collections, you or patient’s guarantor shall pay collections expenses. 4.PROMISE TO PAY. I authorize VSWI Doctors of Chiropractic to furnish complete information to my insurance carrier(s) and/or its (their) intermediaries and to submit a claim for all services rendered by this office. I authorize and direct my insurance carrier(s) and/or its (their) intermediaries to issue payment checks directly to this office for all services rendered and that I am financially responsible to this office for any balance not covered by this authorization. I understand that if I suspend or terminate my care and treatment, any and all fees for professional services rendered to me will immediately be due and payable in full. If it is ever necessary for this office to employ collections counsel and/or take collection measures, I waive all rights to confidentiality, and understand that I am responsible for those collection charges in addition to the fees for professional services.5.INSURANCE PLANS. VSWI will check your insurance carrier(s) out-of-network benefits and eligibility for chiropractic service. We bill your insurance through our billing agency: Meridian Pacific. VSWI may disclose pertinent portions of your financial or medical records to our billing agency Meridian Pacific. Certain insurance plans will not be billed through our billing agency. In such cases a super bill for the purpose of self-submission will be provided per request. 6.SUPER BILLS. Super bills will be given to you to give to your insurance provider per request for all Blue Cross and Blue Shield patients who receive reimbursement checks directly from your insurance company or those plans with a max $25 payout per office visit. These policies will be treated as cash patient and accepts full financial responsibility in accordance with paragraph 4 (Financial Agreement). Some high deductible plans will also not be billed through Meridian Pacific instead a super bill will be provided to you per request. 7. PERSONAL INJURY. For any treatments rendered at VSWI due to a motor vehicle accident you and the patient’s guarantor accepts full responsibility for payment rendered to the office and authorizes VSWI and VSWI’s billing service, Meridian Pacific, to use your health insurance for any non med-pay coverage. The following information must be received prior to treatment: A. Patient’s health insurance information. B. Patient’s auto insurance information. C. 3rd party auto insurance and claim information. CONSENT TO TREATI hereby request and consent to the performance of chiropractic procedures, including various modes of physiotherapy, diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am responsible) by the doctor of chiropractic indicated below and/or other licensed doctor of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as backup for the doctor of chiropractic named below, including those working at the clinic or office listed below or any office or clinic, whether signatories to this form or not. I understand and I am informed that, as is with all health care treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all health care 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, stroke, 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 judgment 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 the doctors of chiropractic will be working on all body parts pertaining to my complaint and give permission for the doctor to treat those areas to my spine, extremities, and all muscle groups ( I.E. Gluts, piriformis, IT band, pectoralis major and minor, ribs, sternum etc.).I further understand that there are treatment available for my condition other than chiropractic procedures. These treatment options include, but not limited self administered, over the counter analgesics and rest; massage therapy, acupuncture, 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 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 of treatment for my present conditions and for any future conditions(s) for which I seek treatment.

Name of the Insured:
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Patient's/Guardian's signature:
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Date:
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