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.
Welcome to our office of chiropractic. Thank you for taking a moment to fill in
our Patient Intake Form. Please fill this form completely
and to the best of your knowledge. Let our staff know if you have any questions.
When complete return it to our office with the bottom authorization checked and
appropriate signatures filled in.
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
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Contact 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.)
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Draw Your Symptoms
Click on a crayon and draw on the body above to indicate your symptoms
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
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
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Secondary Insurance
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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.
Family Health History
Separate details with "," comma as shown above.
(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol,
etc.)
Social History & Life Choices:
Chiropractic Experience
Please select all that apply.
Other:
If yes…
What was the reason for those visits?
Doctor's Name:
Approximate date of last visit:
Reason for this Visit
If you're only here for chiropractic wellness services please skip this section.
Does this concern interfere with:
Results:
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.
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 acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.Private pay patients are expected to provide payment in full at the time of service. We accept cash, check and all major credit cards. We also require a copy of your driver's license. We will call the insurance company to verify your benefits, however, that does not guarantee payment for services that are provided. We will bill your insurance as a courtesy. You are responsible for all deductibles, co-payments and non-covered services at the time services are rendered.If you have been involved in an auto accident, we require a copy of your accident report, auto insurance and all health insurance information. If an attorney is involved, you must return a signed doctor's lien form within 7 business days of your first visit. All accident patients must seek medical treatment within a 14 day period from the date of the accident. Non-emergency chiropractic visits are subject to a $2,500 limit. Emergency chiropractic visits are subject tot a $10,000 limit. If no treatment has been rendered within a 14 day period, you are responsible for full payment.Dr. Randall Laurich is a participating Medicare provider which means we submit your claims to Medicare. Medicare patients are subjected to a $203.00 yearly deductible that must be met before your co-insurance will be applied. Once the deductible is met, Medicare will pay 80% of the allowable fee and you are responsible for 20% of the associated fees unless you have a secondary insurance. The spinal adjustment is the only covered service under Medicare. Maintenance care is not covered by Medicare, nor are the required exam fee of $40.00. Any non-covered service must be paid for at the time of service.Please be aware that any patient account 31 days past due will accrue all responsible collection costs and/or attorney fees. All accounts will be assessed 1.5% per month on the outstanding balance from the date of service. I understand that there is no guarantee that insurance companies, prepaid heath plans or Medicare will cover or pay for all of my charges. I understand that I am responsible for all remaining charges.
Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature