Patient Information (H) (W) _. Accident Information. Insurance Information. Is this visit due to an accident? O Yes O No If yes, what type?

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1 W E L C O M E Date: Patient Information Name: Last First MI address: Mailing Address: City State Zip Phone #:(H) (W) (Other) Can we call you at work? O Yes O No Date of Birth: Sex: O Male O Female SS#: Marital Status: O Single O Married O Divorced O Widowed O Separated O Minor Race: O Caucasian O African American O Asian O Native American O Latin American O Other Ethnicity O Hispanic O Latino O Non-HispanicINon-Latino Occupation: Employer: Employer Address: Phone: How did you hear about our practice? Emergency contact: Name: Relation: Phone#: (H) (W) _ Accident Information Is this visit due to an accident? O Yes O No If yes, what type? O Auto O Work O Other Has it been reported? O Yes O No If yes, to whom? Insurance Information Policy Holder Name: Relationship to patient (if other than self): D.O.B. : Phone#: Do you have health insurance? O Yes O No Name of Carrier: Do you have secondary insurance? O Yes O No Name of Carrier: PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S) Weight-Loss Goals Why do you want to lose weight Current weight? Goal weight

2 Assignment and Release (insured patients) I certify that I (or my dependent) have insurance coverage with and I AUTHORIZE, REQUEST AND ASSIGN MY RIGHTS and INSURANCE BENEFITS TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions. SIGNATURE (X) DATE Form 2

3 Check off any of the following symptoms you have experienced in the past 6 months: 0 Low Back Pain 0 Tension Across Top of 0 Pain in the feet Shoulders 0 Tired/Fatigued 0 Pain between Shoulder 0 Numbness/Tingling in 0 Difficulty Sleeping Blades Arms/Hands 0 Allergies 0 Neck Pain 0 Numbness/Tingling in 0 Digestive Problems 0 Tension/Headaches Legs/Feet 0 Carpal Tunnel 0 Fibromyalgia 0 Pain in the legs 0 Knee Pain Other (Please Explain): Which of the above is worse? How long have you had it? How often does it occur? What does it feel like? What have you done that has helped this problem? What activities would you like to do if this was not a problem? Does this cause you to be: Does this affect your work: Does this affect your life: O O Moody Irritable O O Decision making Poor attitude O Lose patience with O Interrupt Sleep O Decreased productivity spouse/children O Restricted in daily activities O Exhausted at the end of the O Restricted household duties day O Hinders ability to exercise or O Unable to work long hours spouse O Interferes with ability to do hobbies or other activities What have you tried to help relieve/get rid of this problem and how much did it help? (Circle appropriately) O Medications helped: Little Some Much O Physical Therapy helped: Little Some Much O Chiropractic helped: Little Some Much O Exercise helped: Little Some Much O Nutrition helped: Little Some Much O Stretching helped: Little Some Much

4 Informed Consent to Care A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures pe1fonned are usually beneficial and seldom cause any problem. In rare case, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or defo1mities, which would otherwise not come to the attention of the physician. This office does not pe1form breast, pelvic, prostate, rectal, or full skin evaluations. These examinations should be pe1formed by your family physician, GYN, and dermatologist to exclude cancers, abnormal skin lesions that should undergo biopsy/removal or other treatments. This clinic does not provide care for any condition (such as high blood pressure, diabetes, high cholesterol) other than those addressed in your physical medicine care plan. We also do not prescribe or refill ANY controlled substances. All, prescriptions should be refilled by your original prescriber and any new prescriptions should be issued by your p1imary care provider. The patient assumes all responsibility/liability if the patient does not report on health fo1ms any past medical history, illnesses, medicines, or allergies. I agree to settle any claim or dispute I may against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request. Patient's Signature Date CHIROPRACTIC INFORMED CONSENT TO TREAT I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays and/or other tests on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office of clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations, falls, dizziness, headaches, bruises, redness, soreness, burns with modalities and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure, which the doctor feels at the time, based upon the facts then known, and is in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Patient Signature Date

5 Health History Who is your primary care physician? (doctor and/or practice) _ Please check to indicate if you are currently experiencing any of the following conditions: O Neck Pain/Stiffness O Pins/Needles in Arms O Light Bothers Eyes O Sudden Weight Loss O Back Pain/Stiffness O Pins/Needles in Legs O Depression O Loss of Taste O Arm/Hand Pain O Fatigue O Nervousness O Loss of Memory O Leg/Knee Pain O Sleeping Difficulties O Tension O Jaw Problems O Headaches O Loss of Smell O Cold Sweats O Constipation O Dizziness O Allergies O Stomach Problems O Shortness of Breath O Asthma O Blurred Vision O Night Pain O Bowel/Bladder Changes O Nausea O Cold Feet O Chest Pain O Fever O Fainting Please check to indicate if you have ever had any of the following: O Aids/HIV O Cancer O Hepatitis O Osteoporosis O Stroke O Alcoholism O Cataracts O Hernia O Pacemaker O Suicide Attempt O Allergy Shots O Chemical Dependency O Herniated Disc O Parkinson's Disease O Thyroid Problems O Anemia O Chicken Pox O Herpes O Pinched Nerve O Tonsillitis O Anorexia O Diabetes O High Cholesterol O Pneumonia O Tuberculosis O Appendicitis O Emphysema O Kidney Disease O Polio O Tumors/Growths O Arthritis O Epilepsy O Liver Disease O Prostate Problems O Typhoid Fever O Asthma O Fractures O Measles O Prosthesis O Ulcers O Bleeding Disorders O Glaucoma O Migraines O Psychiatric Care O Vaginal Infections O Breast Lump O Goiter O Miscarriage O Rheumatoid Arthritis O Venereal Disease O Bronchitis O Gonorrhea O Mononucleosis O Rheumatic Fever O Whooping Cough O Bulimia O Gout O Multi ple Sclerosis O Scarlet Fever O Heart Disease O Mumps O Other Are you currently under drug and/or medical care? O Yes O No If yes, explain Please list any medications you are currently taking (Be sure to include dosage and frequency) Please list any surgeries and/or hospitalizations you have had (type & date): Please list any allergies: Please list any supplements you are currently taking (vitamins/herbs/minerals): Is there a family history of any of the following conditions? (Indicate family member including parents, grandparents & siblings) O Heart Disease O Cancer O Diabetes O Arthritis _ O Other Do you exercise: O Never O Daily O Weekly O Walks O Runs O Swims Do your work activities mostly involve: O Sitting O Standing O Light Labor O Heavy Labor What is your daily/weekly intake of the following: Caffeine cups/day Alcohol drinks/week Cigarettes packs/day I certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my health. SIGNATURE (X)

6 Review of Systems Please mark if you have experienced any of these symptoms within the last month: Migraines Cardiovascular y N Skin -- Eczema -- Dermatitis -- Excessive Sweating -- Rashes -- Brittle Nails -- Hair Loss -- Easy Bruising -- Increased Bleeding -- Numbness/tingling Genitourinary -- Uterine fibroids -- Ovarian cysts -- Cancer (breast, ovarian, prostate, uterine) Prostate problems -- Emotional/Mental -- Depression -- Anxiety -- Mood Swings -- Irritability -- Memory Loss -- Confusion Energy -- Fatigue -- Hyperactivity -- Restlessness -- Insomnia -- Decreased Libido -- Stress Weight -- Decreased Appetite -- Weight Gain -- Inability to Lose Weight -- Food Cravings -- Binge Eating -- Water Retention

7 X-ray Questionnaire: For women only I request that x-ray films not be taken because: Date PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Patient Name: DOB:_ I acknowledge that I have reviewed the Notice of Privacy Practices of Superior HealthCare. (Please initial one of the following options and sign below.) I wish to receive a paper copy of Privacy Notice. I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office. Please initial below: I acknowledge that it is the policy of this office to leave reminder messages on my answering machine or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing. I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Privacy Officer about my concerns.

8 A BROKEN APPOINMENT IS A LOSS TO EVERYONE. PLEASE INFORM US AT LEAST 24 HOURS IN ADVANCE IF YOU ARE UNABLE TO KEEP YOUR APPOINMENT. THERE WILL BE A $25 CHARGE FOR ALL BROKEN APPOINTMENTS. Signature of Patient/Guardian Date Witness (Office Staff) Date

9 Financial Office Policies Superior Physical Medicine 1. All patients are cash until our staff can verify all insurance coverage(s). 2. Your insurance will be verified promptly and will be reviewed with you if applicable. 3. After coverage and deductible are verified, this office may accept assignment on most policies provided the insured/patient signs an appropriate statement of benefits and/or a lien authorizing payment to be sent to the doctor. 4. Waiting for the insurance payment is a courtesy and it may be withdrawn under certain circumstances. 5. As a patient, it is your responsibility to take care of the co-payment (usually a percent or fixed amount) and any non-covered services in a monthly basis. This office may make payment arrangements on an individual basis. Any such plan or arrangements will be discussed during your report of findings. 6. This office does not warrant or guarantee that your insurance company will pay, nor does this office promise that an insurance company will or should pay the fees charged. Insurance policies are an arrangement between the insurance carrier and the patient/insured. 7. Any service not covered or coverage reductions by your insurance carrier will be the patient's responsibility. 8. This office will submit an insurance claim for you. We will not enter into any dispute with your insurance company. If coverage problems arise, you will be expected to assist directly with your insurance adjuster or agent. Any denied or disputed claims will be treated as uncovered. 9. If your account should go to collections for any reason, it will be the patient's responsibility for any court costs, attorney's fees, and or collection costs incurred in collecting the account balance. 10. I authorize the release of any medical or other records or information necessary to process any claims. 11. All insurance payments, regardless of which company issues a check first, are applied to your account as long as any balance is due. This means refunds are made only after your balance is completed and cleared with this office. 12. If you receive correspondence of checks from your insurance company, you agree to bring these into our office to determine if the checks are on assignment to this office. 13. If you change insurance companies or employers, you agree to provide this office with the current information immediately. 14. If this office gives you a professional accounting discount for treatment and you decide to drop out of care then our standard fees will apply. 15. The office accepts MasterCard, Visa, American Express, personal checks and cash. 16. If you have any questions concerning this or any other matter, please speak with the Front Desk Manager or our Billing Manager prior to seeing the doctor. 17. If you stop care and have a financial agreement signed with our office, you will be responsible for any/all charges that you have incurred at our office. Patient Name: Patient Signature: Date:

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