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.
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.INFORMED CONSENT FOR CHIROPRACTIC TREATMENT AND CAREI hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physiotherapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor or intern, affiliated with Gonstead Wellness, and Salehmohamed Chiropractic Inc.I understand that, as in the practice of medicine, in the practice of chiropractic care there are some risks to treatment, including but not limited to, fractures, disk injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, and is in my best interests.I have read, or have had read to me, the above consent. By signing below I agree to the above, and allow the doctor or intern, affiliated with Gonstead Wellness to perform such. I intend this consent form to cover the entire cause of treatment of my present condition and for any future condition(s) for which I seek treatment.
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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