WELCOME TO FETZER FAMILY CHIROPRACTIC
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1 WELCOME TO FETZER FAMILY CHIROPRACTIC Patient Information Thank you for choosing Fetzer Family Chiropractic for your health care needs. Please complete this form in ink. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help. Today's Date: Parent's address: Child's Name: Birth Date: Address: City: State: Zip Code : Home Phone #: Mother's Name: Cell/Work Phone #: / Father's Name: Cell/Work Phone #: / Preferred contact number: Mother's Home / Cell / Work Father's Home / Cell / Work Would you like to receive a text message / reminding you of an upcoming appointment? Y or N Emergency Contact Phone # Whom can we thank for referring you? Child's Race, Ethnicity and Primary Language Race Please check one Ethnicity Please check one American Indian or Alaska Native Hispanic or Latino Asian Not Hispanic or Latino Black or African American Declined Native Hawaiian or other Pacific Islander Unknown/Unavailable White Other Declined Unknown/Unavailable Is English your primary language? Y or N If no, please list PHI Personal Health Information Personal Health Information regarding your child may be communicated in the following way (please select one or more): No preference In person only Preference specified below: Mailing address may be used for written communication Messages may be left on answering machine at primary phone number listed Voice mail message may be left on primary phone number or cell phone listed Text message may be sent to cell phone
2 Payment/Insurance Information Please read/sign the Fetzer Family Chiropractic Financial Policy and give the front desk a copy of your child's insurance card. Health Questionnaire Reason for today s visit: When did these symptoms begin? How frequent are the symptoms? Constant Frequent Intermittent Occasional When are the symptoms worse? Morning Afternoon Evening No Change Other What relieves the symptoms? What activities are limited by the symptoms? Other doctors seen for this condition: Has your child ever been to a chiropractor before? Y or N Is this condition due to an accident? Y or N If yes, date: Auto Other Current height Weight Previous Surgeries (please list procedure and year): List all Prescription and Over-the-Counter Medications that your child is taking: List all Nutritional and Herbal Supplements that your child is taking: What do you hope to get from your child's visit/treatment? Reduce symptoms Improve sleep Improve behavior Explanation of condition/treatment Diet and Nutritional Advice Preventing symptoms in the future
3 Pregnancy History (Mother): Did you experience any of the following during pregnancy? Severe viral infection during 1 st trimester Breech position Accident or Injury Severe stress Pre-eclampsia Alcohol or drug use Radiation Exposure Hypertension (high blood pressure) Diabetes Back pain Labor and Delivery History: Did you and/or the child experience any of the following during birth? Hospital birth Breech birth Home birth Forceps or vacuum Long and/or difficult labor Fetal distress Rapid delivery Cord around the neck Induced labor Antibiotics Elective c-section Premature delivery Emergency c-section Positional issues ( sunny-side up ) Newborn History: Did the child experience any of the following as a newborn? Required resuscitation/oxygen Prolonged jaundice Poor sleeper Immunizations in hospital If yes, specifiy vaccine: Length at Birth: Health History: Has your child experienced any of the following? Illness accompanied by high fever Headaches Seizure/convulsions Chronic ear infections or fluid Head injury Falls, clumsiness, or poor coordination Neck or back problems Joint problems Scoliosis Adverse reaction to vaccination Uneven skull (cone-head or flat spots) Colic Formula fed Breast fed Difficulty latching/sucking Weight at Birth: Diabetes Hypoglycemia (low blood sugar) Heart condition Trouble with bladder control (enuresis) Digestive disorders (diarrhea / constipation) Asthma Sinus problems Eczema Allergies (food / environmental / chemical) Other: Neurological History: Had your child been diagnosed with any of the following? Hearing loss Anxiety/Depression Vision impairment Obsessive/Compulsive Disorder ADD or ADHD Autism/Autism Spectrum Disorder Dyslexia Other: Did your child crawl (on all fours)? Y N At what age did your child walk unassisted? AUTHORIZATION FOR CARE OF A MINOR I authorize the Doctors of Chiropractic at Fetzer Family Chiropractic to evaluate and treat my son/daughter as they deem necessary. Parent/Guardian Signature: Date:
4 I have read and understand the payment policy of Fetzer Family Chiropractic. I understand that my insurance is an arrangement between myself and my insurance company, NOT between Fetzer Family Chiropractic and my insurance company. I request that Fetzer Family Chiropractic send my claims so that I may obtain insurance benefits. I also understand that if my insurance does not respond within 90 days, or if I suspend or terminate my schedule of care as prescribed by the doctor at Fetzer Family Chiropractic that all charges will be due and payable immediately. Patient s signature (or guardian if patient is a minor) Date Fetzer Family Chiropractic FINANCIAL POLICY Our recommendations are based on a desire to see you get well and stay well. Chiropractic care is covered under many insurance plans. Most of our patients that have health or accident insurance will fall under one of the plans discussed in this policy. Regardless of your coverage, we ll suggest the chiropractic care we think you need. We ask that you read and understand our policy as it applies to your particular situation.
5 Non Insured Patients We request that 100% of each visit be paid is full. We are happy to accept your check, cash, Discover, Master Card, or Visa. We do offer a Time of Service discount of 10%. Fetzer Family Chiropractic is a provider of ChiroHealthUSA, which is a medical discount plan that offers on average discount of 20% if you become a member at the annual charge of $49 for your entire family. This is a popular option for families and patients receiving routine/maintenance care. We would be happy to assist you with any questions. HEALTH INSURANCE Your insurance is an agreement between you and your insurance company, not between your insurance company and our office. We cannot be certain if your insurance covers Chiropractic, although most policies do provide some amount of coverage. The amount they pay varies from one policy to another. When possible, we will call to verify benefits on your insurance; however, the benefits quoted to us by your insurance company are not a guarantee of payment. As a courtesy to you, our office will send in all claims to your insurance company. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services, deductibles or co-pays. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to (six) months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately. MEDICARE We do accept assignment from Medicare. The check is usually sent directly to our office in payment of the services that Medicare will cover which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20%. All other services we provide are NON- COVERED. These services include, but are not limited to, x-rays, examinations, therapies, orthotics, supports, and/or nutritional supplements. Medicare patients are fully responsible for charges of non-covered services. Secondary insurance may or may not pay for these non-covered services. Our office completes and files the forms for Medicare at no charge. SECONDARY INSURANCE Please inform us of any secondary insurance you may have. We will assist you if you need help in filing. ON THE JOB INJURY (Worker s Compensation) If you are injured on the job, your care would likely be paid for under your employer s Worker s Compensation insurance. You will need to inform your employer of the accident first and obtain the name, address of the carrier and claim number of your insurance claim. If you do not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately. PERSONAL INJURY OR AUTOMOBILE ACCIDENTS Please present your auto insurance information, and tell us if you have retained an attorney. There are options available to the PI patient: We are providers for the following companies: Blue Cross Blue Shield of ND, Medica, Sanford, United Healthcare, Medicare, UMR, Medicaid of ND Please inform us if you have a medical/health savings account, sometimes known as a 'flex plan'. We will be happy to provide you with a statement of your charges for reimbursement. 1. Pay cash for your care and we will submit necessary information if requested. 2. We will bill (accept assignment) for the medical portion of your auto insurance. 3. We will accept a Letter of Protection or Doctor s Lien from an attorney and await payment at the time of settlement as long as you remain an active patient.
WELCOME TO FETZER FAMILY CHIROPRACTIC
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PATIENT INTAKE AND MEDICAL INFORMATION
PATIENT INTAKE AND MEDICAL INFORMATION PATIENT INFORMATION: Todays Date: DOB: GENDER: M F SSN (required): Marital Status: Divorced Married Separated Single Widowed Address: City: State: Zip: Phone (H):
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: Weight: Mailing Address:
PERSONAL INFORMATION PATIENT INFORMATION Last Name: _ First Name: _ Middle : Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: _ Weight: Mailing Address: City: State: Zip: Social Security #:
PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
CHIROPRACTIC HEALTH QUESTIONNAIRE
CHIROPRACTIC HEALTH QUESTIONNAIRE Name: SS#: Today s Date: / / Address: City: State: Zip: What you prefer to be called: Age: Birthdate: / / Handedness: Height: Weight: Number of Children: Male Female Marital
Patient Information Form
ALASKA DIGESTIVE AND LIVER DISEASE, LLC Ronald J Boisen, M.D. Daryl M. McClendon, M.D. Jeffrey W. Molloy, M.D. Patient Information Form Patient s Name: Age: DOB: Sex: Male Female Marital Status: S M W
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival)
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival) Patient s Name First Last M.I. Nickname Address # City State Zip code Phone:
PATIENT INFORMATION DATE: / / SS # - - DOB: / / NAME: (last) (first) (middle) ADDRESS: CITY: STATE: ZIP: PHONE (HOME): (CELL):
ADULT NEW PATIENT PACKET PATIENT INFORMATION DOCTOR: DATE: / / SS # - - DOB: / / NAME: (last) (first) (middle) ADDRESS: CITY: STATE: ZIP: PHONE (HOME): (CELL): EMAIL: GENDER: M F Marital Status APPOINTMENT
Patient Health Information Consent Form
Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any
Please bring the medications you are currently taking. If you had x- rays made, please bring the films with you when you come to the office.
Dear Patient: We would like to take this opportunity to thank you for choosing our office for your urologic care and to welcome you to our office. We are pleased that you have chosen us to provide you
To all of our new patients
ATLAS FAMILY Thank you for choosing Atlas Family Chiropractic. We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your
Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX (972)
Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX 75093 (972) 265-8100 Name: Date: Address: City State Zip E-mail: Cell #: Home #: Work #: Birth Date: S.S.#: Single Married Divorced Widowed
FAMILY HISTORY CHILD/CHILDREN S NAME:
FAMILY HISTORY CHILD/CHILDREN S NAME: FAMILY HISTORY (THINK IN TERMS OF THE CHILD S SIBLINGS, PARENTS, GRANDPARENTS, AUNTS, UNCLES AND FIRST COUSINS): ANY ALLERGIES, HAY FEVER, ASTHMA OR ECZEMA? WHO? ANY
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION PATIENT Last Name First Name Email Address FIT Box Address City INSURED PARTY Company Policy No. Group No. Policy Holder Policy Holder DOB Phone State ZIP Cell or Home Phone Student
PATIENT REGISTRATION FORM. Address. Street# Street Name Apt.# City State Zip Code. Employer: Date of Birth: / / Age Month Day Year
PATIENT REGISTRATION FORM Name: Jr. Sr. First Middle Last Prefer to be called: Gender(Sex): M F Married Divorced Single Widowed Race : White Black Asian Indian Other Declined to Provide Ethnicity: Hispanic
Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology TODAY S DATE PATIENT S NAME: BIRTHDATE
Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology PATIENT S NAME: TODAY S DATE BIRTHDATE WAS THERE A DOCTOR WHO REFERRED YOU? No Yes If yes, who Who is your Family or Primary care doctor? WHAT are
Northwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR
rthwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR 97035 503-850-4526 DEMOGRAPHCS Last Name: First Name: MI: Date of Birth / / Gender: SS#:
PATIENT REGISTRATION FORM
Today s PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First: Mi. Init: DOB: Age: SSN: Gen: M F Marital Status: S M D W Race: African American American Indian Asian Caucasian Hispanic Pacific
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
SOUTH SHORE NEPHROLOGY, P.C.
SOUTH SHORE NEPHROLOGY, P.C. Please fill out this form along with all the documents included in the patient packet and bring it with you for your upcoming appointment. Be sure to bring your insurance card(s)
PATIENT REGISTRATION
PATIENT REGISTRATION NAME: (LAST) (FIRST) (INITIAL) S.S.#: ADDRESS: (STREET) (CITY) (STATE) (ZIP) OCCUPATION: EMPLOYER: HOME PHONE: ( ) WORK PHONE: ( ) CELL PHONE:( ) EMAIL: MARITAL STATUS: S M W D BIRTH
PATIENT REGISTRATION FORM
Today s Date / / PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name Last First Middle Is this your legal name? If not, what is your legal name? Birthdate Age Sex q YES q NO / / q M q F q T Street