Malooley Chiropractic
652 Northwest Hwy
Cary, IL 60013

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


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.

Personal Incident History:


If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

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:

Health Problems & Concerns:


Please select all that you have had or currently have.

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

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. Consent To Treat and Payment Authorization I, __________________________________________ (patient) certify that I am the patient [or parent or legal guardian to a Minor]. I have read and understand this Consent to Treat and Payment Authorization. I consent to the collection and use of my information by Malooley Chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize Malooley Chiropractic 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 this signed statement for required insurance submissions. I understand and agree that health/accident insurance policies are an arrangement between me and an insurance carrier. I understand that fees for professional services become immediately due upon suspension or termination of my care or treatment. I understand that if my account has an unpaid balance that hasn’t had any payment activity for the last 30 days, there will be a $5.00 processing fee added to the account each month that there is no payment. I understand that if my account should go to collections, I will also be responsible for all collections fees as well as the unpaid balance. MINORS All Minors (under the age 18) must be accompanied by a parent or legal guardian at their first visit. At that time, a parent or legal guardian may sign below for the patient to be seen unaccompanied in the future. _____________________________________________ ________________________________ Patient or Parent or Legal Guardian Date HIPAA Because of HIPAA Federal regulations protecting your privacy, Malooley Chiropractic wishes to inform you that we will not release any information about you without your consent. We are allowed, however, to release this information to your insurance company or as necessary to get paid for our services. You can have access to your records by simply requesting so in writing. WORKERS COMPENSATION If your condition is the result of a work-related injury, we require that you have an authorization number and the name of the insurance adjuster, otherwise you will be required to pay for the initial visit in full at the time of service. If your workers compensation case is contested, we require payment in full at time of services, or confirmation of commercial health insurance coverage or other liable third party coverage. AUTOMOBILE (PERSONAL) INJURIES If your condition is the result of an automobile accident, we will bill your automobile med-pay insurance. If your med-pay is not available, we may submit the claims to your personal health insurance carrier. If third party liability cannot be confirmed, we will require payment in full at the time services are rendered. MISSED APPOINTMENTS Please help us serve you and others by keeping scheduled appointments. Scheduled appointments should be cancelled at least 24 hours in advance. Our policy is to charge $25 for each missed appointment. RADIOLOGY REPORTS All x-rays that are taken in our offices are automatically sent out to be read by a radiologist. There is an additional $25 charge per x-ray set that will be charged to you that is not covered by your insurance.

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

Signature


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