Chiropractic Arts Center of Austin, PC
4131 Spicewood Springs
Suite L-3
Austin, TX 78759
512-346-3536

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

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?




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:


 

Reason for this Visit

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

Does this concern interfere with:





Results:

For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

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.




Were You Aware That...

Health Problems & Concerns:


Please select all that you have had or currently have.

Authorization

Authorization and Release I certify that I'm the patient or legal guardian listed above. I have read and 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 Chiropractic Arts Center of Austin, P.C. I authorize Chiropractic Arts Center of Austin, P.C.’s doctors and staff to examine and treat my condition as the doctors see fit. Financial and Non-discrimination Policies I understand and agree that all services rendered to me will be charged to me, and I am personally responsible for timely payment of such services. I understand and agree that health and/or 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. I also understand that all individuals have a right to care and no individual will be discriminated against because of race, color, creed, religion, sex, age, sexual preference, national origin, citizenship, marital status, disability, veteran status or any other status or characteristic protected under federal, state, or local laws. Consent to Care I acknowledge that I have read the explanation of chiropractic care available at http://cacaustin.com/online-forms.html. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing care and have freely decided to undergo the recommended care and herby give my full consent to the recommended care and procedures for myself or my minor child in which I have the legal right to select and authorize care for. If my authority to select and authorize this care should be revoked or modified in any way, I will immediately notify this office. Notice of Privacy Practices Acknowledgement I acknowledge that I have read and understand the Notice of Privacy Practices available at http://cacaustin.com/online-forms.html or posted at Chiropractic Arts Center of Austin, P.C. containing a more complete description of uses and disclosures of my health information. I understand that Chiropractic Arts Center of Austin, P.C. has the right to change its Notice of Privacy Practices from time to time and that I may contact them at any time at the address above to obtain a current copy of their Notice of Privacy Practices. I understand that I may request in writing to restrict how my private information is used or disclosed to carry out care, payment or business operations. I also understand Chiropractic Arts Center of Austin, P.C. and it’s employees are not required to agree to my requested restrictions as stated, however will abide by any agreement unless prohibited by this notice. Release of Medical Records I hereby authorize Chiropractic Arts Center of Austin, P.C. to release my personally identifiable health records to me. This includes written and/or digital copies of my radiographic images, exam findings, and/or doctor recommendations. I understand that I take full responsibility for the protection of my private health records released to me. Consent to Contact I acknowledge and agree that Chiropractic Arts Center of Austin, P.C. may contact me at any of the phone numbers or e-mail listed on this form for the purpose related to services I receive at Chiropractic Arts Center of Austin, P.C.

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

Signature


Finalizing Form



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