Complete Spine Solutions
2347 Brockett Road
Tucker, GA 30084
770-938-4606

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.)

   

How did you find out about our office?


Did you hear about our office from an advertisement?

If Yes, Where:

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

If Yes, Where:

Employment Information


Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History


Family/Primary Physician

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Reason for this Visit

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

Does this concern interfere with:





Results:

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:

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

Authorization

OFFICE POLICIES •If you cannot make a scheduled appointment for any reason, you must call the office to let us know. Reschedule for later that day whenever possible. Please do not “No Show” without calling, as we would not be able to offer your time slot to another patient in need. We reserve the right to assess a $25 fee for the second “No Show/No Call” missed appointment. •Payment in full is due at the time services are rendered unless prior payment arrangements have been made. •We accept cash/check/debit card/Visa/MasterCard/American Express/Discover & Care Credit. There is a $30 service charge on all returned checks. POLICIES ON INSURANCE BILLING •For patients with insurance, once your benefits are verified by a staff member, you are required to pay the deductible or co-payment as services are rendered. Insurance carriers do not guarantee benefits; claims are evaluated as they are received; therefore, this office cannot guarantee benefits that are explained to you. Contact your carrier with questions. •Filing of insurance is a courtesy; all charges are your responsibility. You must contact your ins. company on unpaid balances over 30 days. After 60 days, you are expected to settle your account. •If your ins. coverage changes while you are under care, notify the staff in a timely manner. ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO COMPLETE SPINE SOLUTIONS: If I use insurance for services received at CSS, I hereby instruct and direct my insurance company to pay directly to: Complete Spine Solutions at 2347 Brockett Road, Tucker, GA 30084 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 a current manner, any balance of said professional service charges over and above this insurance payment. A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL. I also authorize the release of any information pertinent to my account to any physician, insurance company, adjuster, or attorney involved in my account/case. I certify that I am 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 doctor’s office. I authorize this office and its staff to examine and treat my condition as the doctors see fit. 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 are my responsibility and agree to timely payment for 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. HIPAA NOTICE OF PRIVACY PRACTICES - PATIENT CONSENT FORM: Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Notice contains a Patient Rights section describing your rights under the law. By signing below, you consent to our use and disclosure of your protected health information. The patient understands that: •Protected health information may be disclosed to your primary care physician or used for treatment, payment (incl. insurance companies, attorneys), health care operations or governmental requirements. •The patient has the opportunity to review The Practice’s Notice of Privacy Practices - located in the front office waiting area or on our website at http://tinyurl.com/p59w784, before signing this Consent. •The Practice reserves the right to change the Notice of Privacy Practices. If we change our Notice, you may obtain a revised copy. •The patient has the right to request that we restrict how protected health information is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. •The patient may revoke this Consent in writing at any time and all future disclosures will then cease. Such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. •The Practice may condition receipt of treatment upon the execution of this Consent. I have been provided the opportunity to review the Notice of Privacy Policies located in the office or on the CompleteSpineSolutions.com website. INFORMED CONSENT TO CARE: You are the decision maker for your health care. We will provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. •We may conduct diagnostic or examination procedures if indicated. Examinations or tests conducted will be carefully performed but may be uncomfortable. •Chiropractic care centrally involves a "chiropractic adjustment". There may be additional supportive procedures or recommendations as well. When providing the adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation, reducing pain, and improving neurological functioning and overall well-being. •It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms or soreness, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation/laser therapy/cold packs, fractures, disc injuries, dislocations, strains, sprains, and strokes. •With respect to strokes, there is a rare but serious condition known as a cervical arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in 1 in 1 million to 1 in 2 million cervical adjustments. •It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures & rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a 2nd opinion and to secure other opinions about your circumstances and health care as you see fit. ***If you have any questions about anything you have read here, please ask the Doctor during your initial consultation. I appreciate that it is not possible to consider every possible complication to care. I will be given opportunities to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office. I have read, understand and agree to all the above OFFICE POLICIES, ASSIGNMENT OF BENEFITS, NOTICE OF PRIVACY PRACTICES, and INFORMED CONSENT.

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

Signature


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