WELCOME TO WINDROSE CHIROPRACTIC

Size: px
Start display at page:

Download "WELCOME TO WINDROSE CHIROPRACTIC"

Transcription

1 WELCOME TO WINDROSE CHIROPRACTIC Please complete the following information. We appreciate your cooperation! Chiropractic Case History/Patient Information (Please print) Date: Patient # Doctor Name: Social Security #: Address: City: Zip: Home #: (By giving us your address, you allow us to add you to our ing list. We promise not to abuse the privilege.) Cell #: Fax #: Age: Birth Date: Race: Marital Status: M S W D Number of Children: Occupation Employer: Employer s Address: Office #: Spouse: Occupation: Employer: Name of Nearest Relative: Address: Phone #: Family Medical Doctor: Purpose of this appointment: How were you referred to our office? Page 1 of 9

2 1. What is your major symptom? 2. If this is a recurrence, when was the first time you noticed this problem? How did it originally occur? Has it become worse recently? Yes No Same Better Gradually Worse If worse, when and how? 3. How frequent is the condition? Constant Daily Intermittent Night Only How long does it last? All Day Few Hours Minutes 4. Are there any other conditions or symptoms that may be related to your major symptom? Yes No If yes, describe Are there other unrelated health problems? Yes No If yes, describe 5. Describe the pain: Sharp Dull Numbness Tingling Aching Burning Stabbing Other 6. Is there anything you can do to relieve the problem? Yes No If yes, describe If no, what have you tried to do that has not helped? 7. What makes the problem worse? Standing Sitting Lying Bending Lifting Twisting Other 8. Have you had any broken bones? Yes No If yes, please list and give dates: 9. List any major accident you have had other than those that might be mentioned above: 10. To your knowledge, have you had any diseases, major illnesses, or injuries not indicated on this form either in the past or the present? Yes No If yes, please explain: WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant? Yes No Page 2 of 9

3 Date symptoms appeared or accident happened: Have you ever had the same or a similar condition? Yes No If yes, when and describe: Days lost from work: Date of last physical examination: What surgeries have you had? Please include dates: Have you been treated for any health conditions by a physician in the last year? Yes No If yes, describe: What medications or drugs are you taking? Please check any and all insurance coverage that may be applicable in this case: Major Medical Worker s Compensation Medicaid Medicare Auto Accident Other Name of Primary Insurance Company: Name of Secondary Insurance Company: AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable. Patient s Signature Date: Guardian s Signature Authorizing Care: Date: Page 3 of 9

4 Windrose Chiropractic Kuykendahl, Suite 400 Spring, Texas SPECIFIC AND IRREVOCABLE ASSIGNMENT OF BENEFITS To: Windrose Chiropractic 1. You are authorized to release any information you deem appropriate concerning my health condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred at Windrose Chiropractic. 2. I authorize and assign the direct payment to you of any sum I now or hereafter owe you by my attorney out of the proceeds of any settlement of my case, and by any insurance company obligated to reimburse me for the charges for your services or otherwise obligated to make payment to me or you based in whole or in part upon the charges made for your services. 3. I give direct assignment against any claims against a third party whose negligence may have caused the patient s injury, up to the amount of the bill for treatment. 4. In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges made for your services refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is believed to be correctly set forth under pertinent data below) and authorize you to prosecute said action either in my name or your name as you see fit and further authorize you to compromise, settle or understand that until all company (or companies) contractually obligated, you will refrain from attempts and efforts to collect the amount owed direct from me. I understand that whatever amounts you do not collect from insurance proceeds (whether it be all or part of what is due) I personally owe you. 5. I waive the Statute of Limitations regarding my doctor s right to recover. Date: Signed: Witness: Pertinent Data: Date of injury: Policy #: Name of Insurance: Page 4 of 9

5 LETTER OF NO ACCIDENT OR INJURY I hereby state with my signature that I was not involved in any auto accident, slip and fall, or work injury. My treatment is in no way associated with any 3 rd party, and no other party is responsible or liable for the cost of my treatment. Please process and pay all claims immediately. Sincerely, Patient Signature Date WINDROSE CHIROPRACTIC Massage therapy is offered in our clinic. Some insurance companies cover therapy; however, our therapists are not contracted with any insurance companies. Therefore, the charges will not be filed by our office. If you choose to file, a letter of medical necessity can be obtained and your company may reimburse you for a portion of the charges. We apologize for any inconveniences this may cause you. Patient s signature: Page 5 of 9

6 Windrose Chiropractic Kuykendahl Rd., Ste. 400 Spring, TX Phone (832) Fax (832) Angela D. Kropik, D.C. Lance G. Richardson, D.C. Disclosure of Fees Intermediate Initial History and Exam $ Comprehensive History and Exam $ Brief Office Visit $ Limited Office Visit $ Intermediate Office Visit $ Manipulation (1 2 areas) $ Manipulation (3 4 areas) $ Interferential Muscle Stimulation $ Ultrasound $ Acupuncture $ Therapeutic Massage (15 min.) $ Therapeutic Massage (30 min.) $ Therapeutic Massage (45 min.) $ Therapeutic Massage (60 min.) $ Therapeutic Activities (15 min.) $ Therapeutic Activities (30 min.) $ Therapeutic Activities (45 min.) $ Therapeutic Activities (60 min.) $ Therapeutic Exercises (15 min.) $40.00 Average Billed Per Treatment $71.00 I have read the above codes and fees, and I understand the cost of my care at Windrose Chiropractic, Kuykendahl Rd., Ste. 400, Spring, TX I understand that I am responsible for payment of all deductible and co-payments related to my care. I understand that if my balance is not paid in a timely fashion as determined by the clinic, I promise to pay any and all collection, court, and attorney fees in the collection of my account. I further understand that if my treatment is associated with personal injury or accident claim, all medical bills will be paid at 100% of the above fee schedule regardless of the outcome of my case. I understand that if a check or debit is returned for insufficient funds, I will be charged a $25.00 service charge. I have read and fully understand the above financial terms and prices. Signed Date Witness Page 6 of 9

7 Patient Health Information Consent Form We want you to know how you Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of patient. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient s written consent to need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any given after the request has been presented. 5. For you security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Signature Name of Patient Date Page 7 of 9

8 Notice to Medicare Part B Beneficiaries Advance Notice of Non-covered Services 1. Medicare limits chiropractic reimbursement to manual manipulation. Reimbursement is based on medically necessary correction care only, maintenance care is not covered. 2. Medicare DOES NOT reimburse for charges of exams, x-rays, therapy, supplements or supports from a chiropractor. 3. X-rays and/or an exam may be required to update your condition should a new course of treatment be initiated. Medicare DOES NOT pay for either. 4. Medicare patients will be responsible for deductible amounts, non-covered charges and any denied visits which exceed Medicare guidelines. 5. Medicare secondary policies may be affected by Medicare denials. 6. Medicare supplemental policies only pay for what Medicare approves and does not pay (the manipulation is the only service Medicare approves for Chiropractic). X Our office agrees to Accept Assigment You will be responsible for a 20% co-payment on the allowable charge for manual manipulation in addition to those charges not covered which are listed above. Our office does not accept assignment You will be responsible for all charges incurred. Charges for manual manipulation will be assessed at Medicare s Limiting Charge. Our office will file your claims for you and reimbursement from Medicare will be based on 80% of the allowable charge for manipulation only. I have read and understand the limitations of my Medicare coverage and the affects it may have on any supplement or secondary policies. I am aware that I will be responsible for any charges that Medicare denies or deems over reasonable and necessary. Signature of Patient Date Page 8 of 9

9 Medicare Patients Medicare does NOT cover X-rays or any therapy with the exception of manual manipulation of the spine (adjustments) in a chiropractic office. None of the SUPPLEMENTAL plans will cover the cost of therapy or X-rays. They only cover the 20% of the manipulation charge that Medicare does not pay. Some secondary plans may cover a portion of the therapy and x- rays, but are often subject to a deductible. If you wish to receive therapy and x-rays in our office, even if it is NOT covered by Medicare or your Supplemental insurance, we can provide the service per your request. For a list of charges, please ask our front desk receptionist. Beginning in 2013, the out of pocket deductible for Medicare is $ Sincerely, Windrose Chiropractic Page 9 of 9

Patient Health Information Consent Form

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

More information

WELCOME TO OUR OFFICE

WELCOME TO OUR OFFICE WELCOME TO OUR OFFICE We realize that this is your first visit to our office, and our past experience has shown us that new patients have many unanswered questions on their minds. Our staff will attempt

More information

PATIENT APPLICATION FORM

PATIENT APPLICATION FORM PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very

More information

chiropractic Bringing Out The Best In You!

chiropractic Bringing Out The Best In You! chiropractic Bringing Out The Best In You! New Patient Welcome To Our Office SHAWN P. NEVILLE, DC Kennedy Chiropractic 4140 Crain Highway Waldorf MD 20603 301.645.7770 drneville.com drshawn@drneville.com

More information

PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber

PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber PATIENT INFORMATION : Please present insurance cards to receptionist First Name: Last Name: Date of Birth: - - Sex: Male Female Address: City: Cell Phone #: ( ) - M.I.: APT: State: Zip Code: Home #: (

More information

Patient Registration & Health History

Patient Registration & Health History Patient Registration & Health History Today s Date: / / How did you hear about us? Legal Name: How do you prefer to be addressed? Address: City: State: Zip: Date of Birth / / Age: Gender: M / F Marital

More information

SHOOK FAMILY CHIROPRACTIC, INC.

SHOOK FAMILY CHIROPRACTIC, INC. PATIENT APPLICATION FOR TREATMENT PLEASE CIRCLE THE TYPE OF CARE DESIRED: TEMPORARY LASTING RELIEF DATE: Name: SSN: Date of Birth: Address: City: State: Zip: Cell: Home: Work: Name of Spouse: Ages of Children:

More information

City: State: Zip: Home ( ) Cell ( ) Work ( ) Who Referred You? Phone ( ) Address: City: State: Zip:

City: State: Zip: Home ( ) Cell ( ) Work ( )   Who Referred You? Phone ( ) Address: City: State: Zip: Today s : First Name: M.I. Last Name: Address: City: State: Zip: Apt Home ( ) Cell ( ) Work ( ) Email: of Birth: Marital Status: S M D W Sex: F / M Social Security # - - Who Referred You? Phone ( ) Address:

More information

Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX (972)

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

More information

The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in

The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in Patient Information Thank you for choosing our practice for your chiropractic needs. Please

More information

Chiropractic Case History / Patient Information

Chiropractic Case History / Patient Information Chiropractic Case History / Patient Information Date: Name: Social Security #: Home Phone:( ) Address: City: State: Zip: E mail address: Cell Phone:( ) Age: Birth Date: / / Marital Status: M S W D Occupation:

More information

Welcome to Phillips Family Chiropractic

Welcome to Phillips Family Chiropractic Welcome to Phillips Family Chiropractic Name: Age: DOB: / / SS# / / Address: City: State: Zip Code: Phone: ( ) - Employer: Occupation: Circle One: Single / Married Number of Children: Email: Spouse: Employer:

More information

Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?

Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)? Welcome to Rizzo Chiropractic Holistic Health and Wellness Center Check the following services you are interested in: Chiropractic Physical Rehabilitation Nutritional Analysis (Hair, Blood & Urine) Detox

More information

PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:

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

More information

Chiropractic Case History/Patient Information

Chiropractic Case History/Patient Information 1 Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E. Chiropractic Case History/Patient Information 100 Ridgeway St., Suite 8 Hot Springs, Arkansas 71901 P 501-463-9477 F 501-463-9478 Date: Patient # Doctor:

More information

BACK-HEALTH CHIROPRACTIC INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC THIS SECTION REFERS TO PATIENT ONLY

BACK-HEALTH CHIROPRACTIC INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC THIS SECTION REFERS TO PATIENT ONLY INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC PATIENT THIS SECTION REFERS TO PATIENT ONLY Patient: LAST FIRST MIDDLE Address: City, State, Zip: Cell Phone ( ) of birth Male Female Social

More information

Are you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure

Are you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure Patient s Full Name: of Birth: Age: Address: City: State: Zip: Patient Social Security #: Gender: Height: Weight: Cell Phone: Other Phone: E-Mail: Preferred appointment reminder: ( )Text: Cell Phone Provider:

More information

Informed Consent for Physical Therapy Services

Informed Consent for Physical Therapy Services Informed Consent for Physical Therapy Services The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative

More information

Total Wellness Medical Care. Patient Medical History

Total Wellness Medical Care. Patient Medical History Today s date: PCP: Patient's last name: Mr. Mrs. Marital Status: (circle one) Patient s first name: Ms. Miss Single/Married/Divorced/Separated/ Widowed Is this your legal name? Yes or No If not, what is

More information

Chiropractic Case History

Chiropractic Case History Chiropractic Case History Name Sex M F Date Address City State Zip H. Phone( ) W. Phone Date of Birth Age Cell Phone ( ) Email Address: Referred by Social Security # Occupation Employer Have you ever received

More information

New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, Office: (830) Fax: (830) NewBraunfelsWellness.

New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, Office: (830) Fax: (830) NewBraunfelsWellness. New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, 78130 Office: (830)625-9255 Fax: (830)643-9255 NewBraunfelsWellness.com PATIENT INFORMATION DATE: Legal Name: Nickname: Address:

More information

PS CHIROPRACTIC PATIENT CASE HISTORY

PS CHIROPRACTIC PATIENT CASE HISTORY PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security

More information

Welcome to our office!

Welcome to our office! 2007 Rainbow Drive Gadsden, AL 35901 Ph: 256-543-0009 Fax: 256-549-1221 Patient Information Page 1of 2 Welcome to our office! Dr. Shan Tian, D. C. Patient Information Please complete all questions. Today

More information

Name: Employer: Phone: Phone: Social Security: Occupation: Previous Therapy: Primary Doctor: Phone number: Fax Number: Referring Doctor:

Name: Employer: Phone: Phone: Social Security: Occupation: Previous Therapy: Primary Doctor: Phone number: Fax Number: Referring Doctor: PATIENT INTAKE FORM Patient Information Hands On Physical Therapy Please fill this form out completely. Thank You! Name: Employer: Address: City/State/Zip: Address: City/State/Zip: Phone: Phone: Date of

More information

ACIC PHYSICAL THERAPY

ACIC PHYSICAL THERAPY ACIC PHYSICAL THERAPY PATIENT INFORMATION NAME (first, last): DATE: HOME PHONE: CITY: STATE: ZIP: SSN: DRIVER S LICENSE #: EMAIL: SEX: M F DATE OF BIRTH: AGE: DATE OF INJURY : CAUSE OF INJURY: REFERRING

More information

Greenberg Chiropractic LLC REGISTRATION FORM (Please Print)

Greenberg Chiropractic LLC REGISTRATION FORM (Please Print) Today s Date: LLC REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Miss Marital status: Mrs. Ms. Single Mar Div Sep Wid Is this your legal name? If not, what

More information

Patient Case History

Patient Case History Patient Case History Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Email Address: Preferred Contact: Home Phone Cell Work E-mail Employer & Occupation: Date of Birth:

More information

Patient Information. Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other

Patient Information. Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other Patient Information Date: Name: Birth Date: Age: Marital: M S W D Address: City: State: Zip: E-mail address: Phone: Occupation: Employer: Spouse: Occupation: Employer: How many children? Names and ages

More information

CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION

CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION PATIENT INFORMATION INSURANCE INFORMATION Patient Name: : Address: Birthdate: Responsible for this account: Relationship to Patient: Insurance Co.: Group #: ID #: SS Number: Sex: M F Age: Employer/School:

More information

Patient Demographics

Patient Demographics Patient Demographics Name / / How do you prefer to be verbally addressed? Address City State Zip Phone: Home Work Cell Email SSN of birth / / Age Marital Status: M S W D Other Spouse s Name: Employer Address

More information

ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE

ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE WELCOME to our office! Please allow our staff to make a photocopy of your insurance card(s) (if applicable). Please Print Clearly PERSONAL INFORMATION: Patient Name: Preferred Name: Address: City/State/Zip:

More information

W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By

W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By W E L C O M E PATIENT INFORMATION Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By Date of Birth Social Security # - - Gender: Male Female Marital Status (please circle):

More information

Stinnett Chiropractic we correct pinched nerves

Stinnett Chiropractic we correct pinched nerves Stinnett Chiropractic we correct pinched nerves Date: First Name: Last Name: Address: City: State: Zip: Home Phone: Cell Phone: Gender: Male Female Birth Date: Marital Status: Single Married Divorced Widowed

More information

3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:

3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact: Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full

More information

Perpetual Motion Physical Therapy, Inc. Patient Information

Perpetual Motion Physical Therapy, Inc. Patient Information Perpetual Motion Physical Therapy, Inc. Patient Information Date Patient Information Name Last First MI Address Birth Date Age Social Security Sex: Male Female Contact Phone Work Phone Email Employer Occupation

More information

PATIENT INFORMATION. Street address: Social Security no.: Home phone no.: ( ) City: State: ZIP Code:

PATIENT INFORMATION. Street address: Social Security no.: Home phone no.: ( )  City: State: ZIP Code: Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Married / Divorced / Separated / Widow Is this your legal name? If not, what

More information

Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip

Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone  . Address City State Zip PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address

More information

Automobile Accident Questionnaire

Automobile Accident Questionnaire Automobile Accident Questionnaire Date of Accident: Time of Day: Please explain in detail: Name of driver in your vehicle: Name of driver in other vehicle: Type of vehicle you were driving: How many passengers

More information

PATIENT CASE HISTORY

PATIENT CASE HISTORY Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM 87505 505-984-0006 www.spchiro.net PATIENT CASE HISTORY Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell

More information

AMR PAIN AND SPINE CLINIC, LLC NABIL AHMAD, MD

AMR PAIN AND SPINE CLINIC, LLC NABIL AHMAD, MD AMR PAIN AND SPINE CLINIC, LLC NABIL AHMAD, MD Today's : Email: Patient Last Name: First: Middle: of Birth: / / Sex: (circle) Male Female Marital Status: (circle) M S D W Street Address: Social Security

More information

First Name: M.I. Last Name: Date of Birth: Marital Status (circle one): Never Married Married Divorced Legally Separated. Widowed Partner Other

First Name: M.I. Last Name: Date of Birth: Marital Status (circle one): Never Married Married Divorced Legally Separated. Widowed Partner Other Today s Date: Patient Information First Name: M.I. Last Name: Date of Birth: SSN: Gender (circle one): M F Marital Status (circle one): Never Married Married Divorced Legally Separated Widowed Partner

More information

Welcome! And thank you for choosing Advanced Physical Therapy, Inc.

Welcome! And thank you for choosing Advanced Physical Therapy, Inc. Welcome! And thank you for choosing Advanced Physical Therapy, Inc. Our mission is to offer you the highest quality care in a comfortable, efficient and safe manner. Your appointment is on at with. From

More information

Integrated Spinal Solutions Patient Information

Integrated Spinal Solutions Patient Information Integrated Spinal Solutions Patient Information Patient Name: City/State/Zip: Today s Date: Home Telephone: Work Telephone: Birth Date: Age: Cellular Telephone: Height: Weight: Employer s Name: Social

More information

Name: Social Security: Address: City: State: Zip: Birthdate: Age: address: Cell Telephone: ( ) Fax: ( )

Name: Social Security: Address: City: State: Zip: Birthdate: Age:  address: Cell Telephone: ( ) Fax: ( ) Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will

More information

(Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION. If not, what is your legal name? (Former name): Birth date:

(Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION. If not, what is your legal name? (Former name): Birth date: Today s date: (Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION Last name: First: MI: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your

More information

CHIROPRACTIC PATIENT REGISTRATION AND HISTORY

CHIROPRACTIC PATIENT REGISTRATION AND HISTORY CHIROPRACTIC PATIENT REGISTRATION AND HISTORY Today s Date: / / Date Symptoms began: / / Is your condition due to an accident? Yes No Type: Auto Work Home Other Name : Address: Last First Middle Street

More information

Joint Chiropractic Case History/Patient Information

Joint Chiropractic Case History/Patient Information 1 Joint Chiropractic Case History/Patient Information Name: Date: Social Security # Birth Date: Race: Marital Status: M S W D Address: City: State: Zip: E-mail address: Cell: Home: Work Occupation: Employer:

More information

THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Employer s Name School

THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Employer s Name School THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Sex: M F Employer s Name School Contact Information: Mailing Address City State Zip

More information

Bailey Behavioral Health, LLC Treatment Questionnaire

Bailey Behavioral Health, LLC Treatment Questionnaire Bailey Behavioral Health, LLC Treatment Questionnaire (Please Print) Patient Name Date Address: City: State: Zip Code: Age: Date of Birth: Social Security : Home Phone Number: Cell: Marital Status: (Circle)

More information

Spinal & Sports Care Clinic, PS E Sprague Ave., Spokane Valley, WA 99216

Spinal & Sports Care Clinic, PS E Sprague Ave., Spokane Valley, WA 99216 Spinal & Sports Care Clinic, PS 12905 E Sprague Ave., Spokane Valley, WA 99216 First Name (Legal): (MI): Last Name: Social Security Number: / / Birth Date: / / Married! Single! Other! Mailing Address:

More information

Patient Health Questionnaire

Patient Health Questionnaire Patient Health Questionnaire Account # Patient Name DOB / / 1. Describe your symptoms/complaints or limitations: 2. Please describe how your problem began: 3. When did your symptoms begin/specific date

More information

Patient Health Information Consent Form

Patient Health Information Consent Form Patient Health Information Consent Form We want you to know your Patient Health Information (PHI) is going to be used in this office as well as your rights concerning those records. Before we will begin

More information

Personal Insurance Intake Form

Personal Insurance Intake Form Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:

More information

Patient Registration Form

Patient Registration Form Patient Registration Form Patient Information Account # : Address: Primary Phone: Please indicate the best number for your appointment reminder calls: Home Cell Text Alternate Phone: Email: May we contact

More information

Thank you for choosing Dr. Jesse DeLee for your care. The staff and Dr. DeLee would like to ensure your experience is a pleasant one.

Thank you for choosing Dr. Jesse DeLee for your care. The staff and Dr. DeLee would like to ensure your experience is a pleasant one. Dear Patient, Thank you for choosing Dr. Jesse DeLee for your care. The staff and Dr. DeLee would like to ensure your experience is a pleasant one. In order to better serve you, we ask that you arrive

More information

Welcome to Southwest Diagnostic Center!

Welcome to Southwest Diagnostic Center! Patient Information Form PATIENT INFORMATION Welcome to Southwest Diagnostic Center! Name: Last Name First Name MI Address: City: SS # Email: State: Zip: Sex: M F Age: Birth date: Marital Status: Patient

More information

Olde Naples Chiropractic Health Center

Olde Naples Chiropractic Health Center Patient Full Name: E-Mail Address: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Emergency Contact Name/number: Occupation: Status: Employed Full Time Student Part Time Student

More information

PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:

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

More information

Patient Information. Insurance Information Who is responsible for this account? Relationship to Patient. Insurance Co: Member ID:

Patient Information. Insurance Information Who is responsible for this account? Relationship to Patient. Insurance Co: Member ID: Patient Information Today s Date: Birth Date: SS#: First Name: M. I.: Last Name: Address: City: State: Zip: Sex: M F Age: Email: Cell: ( ) Home: ( ) Emergency Contact: Relationship: Cell: ( ) Home: ( )

More information

chiropractic Bringing Out The Best In You!

chiropractic Bringing Out The Best In You! chiropractic Bringing Out The Best In You! New Patient Welcome To Our Office SHAWN P. NEVILLE, DC Kennedy Chiropractic 4140 Crain Highway Waldorf MD 20603 301.645.7770 drneville.com drshawn@drneville.com

More information

Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM

Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM PATIENT MEDICAL HISTORY FORM Patient Medical History Form DATE: Last Name: First Name: Chart#: Birth Date: Sex: Male / Female Height: Weight: PATIENT HISTORY AND SAFETY QUESTIONS Physician Name: Do you

More information

GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP

GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP 34 Long Pond Road Plymouth, MA 02360 (508) 747-1434 New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic

More information

Worker s Compensation Intake Form

Worker s Compensation Intake Form Worker s Compensation Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:

More information

PATIENT REGISTRATION

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

More information

New Patient Registration

New Patient Registration New Patient Registration Personal Information Last Name: First Name: Middle initial: Street Address: City: State: Zip: Birth date: Age: Sex: M F Social Security Number : Home phone: ( ) Work phone: ( )

More information

Physical Therapy with care and knowledge

Physical Therapy with care and knowledge Patient Demographic Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Primary Phone: Secondary Phone: D.O.B: Social Security: Driver s License Number: May we leave a message?

More information

Austin Kinesiology And Chiropractic

Austin Kinesiology And Chiropractic PATIENT INFORMATION Patient Name: Date of Birth: Sex: M F Age: Soc. Sec. #: - - Photo ID #: State: Address: City, State, Zip: Mobile Phone: Home Phone: Work Phone: Email address: We will not share your

More information

South Lake Pain Institute

South Lake Pain Institute Welcome to South Lake Pain Institute We are honored that you have chosen us as your health care provider. Our goal is to provide the highest quality care for all of our patients in a timely and respectful

More information

Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you.

Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you. Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you. Name: Social Security: Address: City: State: Zip: Birthdate: Age: E-mail

More information

Xcel Rehab. Patient Information

Xcel Rehab. Patient Information Xcel Rehab Patient Information Historical Data: Name: Date: First MI Last Sex: Male Female Marital Status: Married Single Divorced Address: City: State: Zip Code: Phone: Home Cell Email Address: Date of

More information

Whom or What May We Thank For Your Referral? Employment Information: Emergency Contact:

Whom or What May We Thank For Your Referral? Employment Information: Emergency Contact: Date: Patient Demographics: Last Name: First Name: MI: DOB: / / Age: Gender: M / F SS#: - - Marital Status: #of Children: Employment Status: Address: PO Box # City: State: Zip: Home Phone: Cell Phone:

More information

Brannon Family Chiropractic 197 East Brannon Road Nicholasville, KY (859) (Phone) (859) (fax)

Brannon Family Chiropractic 197 East Brannon Road Nicholasville, KY (859) (Phone) (859) (fax) Brannon Family Chiropractic 197 East Brannon Road Nicholasville, KY 40356 (859) 971-0370 (Phone) (859) 971-0650 (fax) Patient Information Date: Social Security # Patient Name: Address: City: State: Zip:

More information

1. PATIENT INFORMATION

1. PATIENT INFORMATION Runnels Chiropractic 32 South 9 th Street - Richmond, IN 47374 (765) 96 CHIRO (24476) www.runnelschiro.com 1. PATIENT INFORMATION Today s _ Full Name SSN Age DOB Address City State Zip Height Weight Race

More information

Pediatric Intake Form

Pediatric Intake Form Child s Legal Name: Today s Date: / / Address: City: ST: Zip: Home Phone: Parent s Cell Phone: Date of Birth: / / Age: Gender: M F Social Security #: Mother s Name: Father s Name: Sibling s Name(s) and

More information

KRAIG R. PEPPER, D.O. P.A.

KRAIG R. PEPPER, D.O. P.A. Thank you for choosing Dr. Kraig Pepper, D.O. P.A. for your care. The following is required to provide you with the quality medical care. The doctor and staff will review this information and place it

More information

WELCOME. one ABOUT YOU. Patient File # Today s Date: / / Birth date: / / Age: Social Security #: Mailing Address: City State Zip.

WELCOME. one ABOUT YOU. Patient File # Today s Date: / / Birth date: / / Age: Social Security #: Mailing Address: City State Zip. Patient File # WELCOME one ABOUT YOU Today s Date: / / Your Name: LAST FIRST MI Male Female Birth date: / / Age: Social Security #: Mailing Address: City State Zip Home Phone #: Work Phone #: Ext: Mobile

More information

Patient Registration. D. INSURANCE (if applicable)

Patient Registration. D. INSURANCE (if applicable) Patient Registration A. PATIENT Account #: Address: City: State Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone DOB: SSN #: Gender: Male Female E-MAIL: Check here to receive Electronic

More information

AUTO ACCIDENT INTAKE FORM

AUTO ACCIDENT INTAKE FORM AUTO ACCIDENT INTAKE FORM Last First Middle Birthdate / / Address City State Zip Phone Number (cell) (home) Today s Date / / Email Occupation Employer Spouse s Name Spouse s Phone Number Who may we thank

More information

RD Physical Therapy & Wellness, LLC

RD Physical Therapy & Wellness, LLC RD Physical Therapy & Wellness, LLC Tel: 443-253-4603 Fax: 410-720-2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 Patient information: Registration Form Last name: First

More information

SHAWN A. HAYDEN, MD, PHD PATIENT PERSONAL INFORMATION. Primary Complaint Injury Date / /

SHAWN A. HAYDEN, MD, PHD PATIENT PERSONAL INFORMATION. Primary Complaint Injury Date / / SHAWN A. HAYDEN, MD, PHD PATIENT PERSONAL INFORMATION Date: / / Primary Complaint Injury Date / / Work-related: Yes No Auto Accident-related: Yes No Slip and Fall: Yes No Patient s Name: First MI Last

More information

NEW PATIENT INFORMATION FORM

NEW PATIENT INFORMATION FORM 3271 N. Milwaukee St. Boise, ID 83704 tel: (208) 629-5374 fax: (208) 629-5394 www.theicim.com NEW PATIENT INFORMATION FORM Personal: Last Name: First Name: Middle Initial: : Address: City: State: Zip:

More information

entral Chiropractic Center

entral Chiropractic Center Patient Information Date: Name Sex M F Birthdate last middle initial first Address Marital Status Single Married Widowed Separated Divorced Social Security # Occupation Primary Phone Secondary Phone Emergency

More information

HEALTH QUESTIONNAIRE. Today s Date Date of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No

HEALTH QUESTIONNAIRE. Today s Date Date of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No Name HEALTH QUESTIONNAIRE Today s of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No If yes, type and amount: Alcohol Use: How many drinks do you have per week? Hand Dominance: Left

More information

Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.

Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT. Please arrive to your initial appointment at least 15 minutes early. For all following appointments, please arrive 5 minutes prior to you scheduled appointment time. To avoid waiting unnecessarily remember

More information

NEW PATIENT INFORMATION. Name: (Last) (First) (Middle) DOB: Address: City: State: Zip: Home #: Work #: Cell#: -

NEW PATIENT INFORMATION. Name: (Last) (First) (Middle) DOB: Address: City: State: Zip: Home #: Work #: Cell#:  - NEW PATIENT INFORMATION Name: (Last) (First) (Middle) DOB: Address: City: State: Zip: Home #: Work #: Cell#: E-Mail- SS#: Marital Status (S-M-Sep-D-W) Sex: (Male/Female) Age: Employer: Work Title: Name

More information

*Married *Widowed *Single *Minor *Separated *Divorced *Partnered for years

*Married *Widowed *Single *Minor *Separated *Divorced *Partnered for years Name Last Name First Name M.I. Address City State Zip E-mail Birthdate Age Sex *M *F Occupation Employer/School Employer/School Address Employer/School Phone ( ) *Married *Widowed *Single *Minor *Separated

More information

Orange N. Harbor Blvd., Suite B Fullerton, CA Phone: Fax: New Patient Form. Address: City: State: Zip:

Orange N. Harbor Blvd., Suite B Fullerton, CA Phone: Fax: New Patient Form. Address: City: State: Zip: , CA 92866 New Patient Form New Patient: HMO PPO Medicare Work Comp Lien Other Name: Date: Home Phone: Cell: Work: Email: Social Security: DOB: Gender: Drivers License #: Referring Physician: Phone: Primary

More information

Family History: Cancer Diabetes High Blood Pressure Heart Problems/Stroke Rheumatoid Arthritis

Family History: Cancer Diabetes High Blood Pressure Heart Problems/Stroke Rheumatoid Arthritis INITIAL HEALTH STATUS Sex M/F Patient Name: Birthdate: Age: Address: City: State: Zip: Phone ( ) Email: Occupation: Employer: Work Phone( ) Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber

More information

Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas Patient Insurance Information

Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas Patient Insurance Information Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 972-312-9310 New Patient Information / Change of Information : New Patient Change

More information

Markley Chiropractic & Acupuncture, L.L.C W Baker St Plant City, FL Patient Name: Nickname/Preferred Name:

Markley Chiropractic & Acupuncture, L.L.C W Baker St Plant City, FL Patient Name: Nickname/Preferred Name: New Patient Information PLEASE Welcome! PRINT Please CLEARLY: allow our staff to photocopy your driver s license & insurance Today s card Date: (if applicable) / /20 Patient Name: Nickname/Preferred Name:

More information

Please list all current medications and supplements that you are taking:

Please list all current medications and supplements that you are taking: PATIENT HEALTH AND MEDICAL HISTORY Today s Date: Chief Complaint for Today s Visit: Was this injury gradual or sudden onset? Date of sudden onset: Please explain: Do you have a history of present symptoms?

More information

PARAGON Physical Therapy, PC

PARAGON Physical Therapy, PC WELCOME TO PARAGON Physical Therapy. Who can we thank for referring you? We appreciate you choosing PARAGON Physical Therapy, PC to be your provider of physical therapy services. If you would not mind,

More information

APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation

APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation APM PATIENT INFORMATION Date: / / Name: / / (Last) (First) (MI) Date of Birth / / SS# - - Sex: q Male q Female Address: City State Zip Home Phone # ( ) Work Phone # ( ) Circle preferred number for communication

More information

Hun Chiropractic 1 Creekview Ct, Suite B Greenville, SC P: F:

Hun Chiropractic 1 Creekview Ct, Suite B Greenville, SC P: F: 1 Creekview Ct, Suite B Greenville, SC 29615 Personal Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: Age: Social

More information

Preferred Name: Social Security # Date of Birth Male Female. Contact Phone #1 #2 #3

Preferred Name: Social Security # Date of Birth Male Female. Contact Phone #1 #2 #3 Preferred Name: Please allow a few minutes at each visit for us to evaluate your progress and collect any necessary documentation for your billing agreement with us. Note if injury caused by: Car Accident

More information

New Patient Registration & Financial Policy

New Patient Registration & Financial Policy New Patient Registration & Financial Policy Financial Policy Thank you for choosing Life Wellness Centre to assist you in achieving and maintaining your health and well-being. We are committed to your

More information

To all of our new patients

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

More information

HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information

HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information Patient Information Name birth date Address (street) apt. # (town, state, zip) Telephone: home cell phone Guardian (if a minor) work e-mail relationship Address (if different) telephone Employer Occupation

More information

NEW PATIENT INFORMATION

NEW PATIENT INFORMATION 12101 W. Parmer Lane Ste. 200 Cedar Park, Texas 78613 Phone: 512.363.5178 Fax: 512.339.2664 Welcome!!! Please allow our staff to photocopy your driver s license and insurance or Medicare card (if applicable).

More information

Patient Registration. D. INSURANCE (if applicable)

Patient Registration. D. INSURANCE (if applicable) A. PATIENT Please Print Legibly Account #: Address: City: State: Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone Patient Registration DOB: SSN #: Gender: Male Female E-MAIL: Check here

More information