IF THE INSURANCE INFORMATION IS NOT IN YOUR NAME WE MUST HAVE THE FOLLOWING.

Transcription

1 A FAMILY TRADITION ROBERTS CHIROPRACTIC CENTER, PA Date of appointment: Name: Last First Middle Name No nicknames please Birth date Address: Please no P. O. Boxes Age: Sex: F M City State Zip Are you Hispanic? Yes No Preferred language Race ADDRESS: By providing your address you are allowing our office to use this as a form of communication, ie correspondence, communication or newsletters. Home Phone ( ) Cell phone Social Security Number Who is your primary treating physician? MARITAL STATUS (Please circle one) Single Married Divorced Separated IF THE INSURANCE INFORMATION IS NOT IN YOUR NAME WE MUST HAVE THE FOLLOWING. Whose name is the insurance under? Their address: Their social security Number: Their date of birth Sex M F What is your relationship to this person?

2 EMPLOYMENT DATA: Employer Name: Employer address: City: State: Zip: Work Phone number: By signing this consent to treat you are also giving us permission to leave messages on your answering machine/voice mail. Patient consent for treatment Guardian consent for treatment In Case of emergency, notify Phone Name of nearest relative not living with you Phone: Address Fees at this office will be paid by: PATIENT'S SIGNATURE I will be paying today by Cash Check Credit Card

3 ROBERTS CHIROPRACTIC CENTER, P.A. APPLICATION FOR FLOIRDA NO FAULT BENEFIT Date Our policyholder Date of accident File No. To enable us to determine if you are entitled to benefits under the Florida automobile reparations reform act, please complete this form and return it promptly. To: Claim Department Your Name Phone No. Home Business Your Address (no. Street, City or Town DOB Social Security # State and Zip Code) Permanent Address, if different. How long have you lived in Florida? Date & Time of Accident Place of Accident (Street, City or Town & State Brief Description of Accident & Vehicles involved. Describe automobiles owned by you or any member of your family: Automobile Owner Insurer Policy Number As a result of this accident were you injured? Yes No If you answered yes, complete the rest of this form. If no, sign here and return this form to us. Signature: Date: Describe your injury. Were you treated by a doctor? Date of 1 st treatment: Doctor s name & address: If you were treated in a hospital, were you an in-patient Or out-patient Hospital s Name & address:

4 Amount of medical bills to date $ Will you have more medical expense? Have you received or are you eligible for payments under Medicaid? Did you lose time from work as a result of your injury? If yes, amount lost to date $ What is your average monthly wage or salary? $ If you lost wages: Date disability from work began Date you returned to work At the time of your accident were you working for your employer? Have you received or are you eligible for payments under any workmen s compensation or unemployment law? If yes, amount $ Per Week Per Month Who pays you these benefits? List names and addresses of your present employer(s) and give your occupation and dates of employment for each: Employer & address Your occupation from to Employer & address Your occupation from to Employer & address Your occupation from to As a result of your injury have you had any other expenses? Yes No If yes, explain on reverse side. Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty or a felony of the third degree. I HEREBY AUTHORIZE RELEAASE OF MEDICAL INFORMATION INCLUDING, BUT NOT LIMITED TO, MEDICAL BILLS AND REPORTS TO SUCH PARTIES AS THE COMPANY MAY DEEM NECESSARY TO PERFECT ITS RIGHTS OF RECOVERY UNDER THE NO-FAULT ACT. Signature: Date: Important: 1. To be eligible for benefits complete and sign this application. 2. Sign attached authorization(s). 3. Return promptly with any medical bills you have received to date. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THIRD DEGREE.

5 AUTHORIZATION FOR MEDICAL INFORMATION THIS AUTHORIZATION OF PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAY AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE FLORIDA NO-FAULT AUTO INSURANCE LAW (CHAPTER F.S.) Signature Date AUTHORIZATION FOR WAGE AND SALARY INFORMATION THIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES OR SALARY WHILE EMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE FLORIDA NO-FAULT AUTO INSURANCE LAW (CHAPTER F.S.). Signature Date Social Security No.: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THIRD DEGREE.

6 Informed Consent PATIENT NAME: Date: To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. The nature of the chiropractic adjustment The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. This may cause an audible pop or click much as you have experienced when you crack your knuckles. You may feel a sense of movement. Analysis/Examination/Treatment As a part of the analysis, examination and treatment you are consenting to the following procedures: Spinal manipulative therapy Ultrasound Hot/cold packs Radiographic studies Interferential Physical examination Intersegmental traction Diatherm Myofascial release Percussion massage Therapeutic exercise Other: The material risks inherent in chiropractic adjustment. As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: muscle strain, joint sprain and costovertebral strains. Some patients will feel some stiffness and soreness following the first few days of treatment. However, complications are generally rare. I will make every reasonable effort during the examination to screen for contraindications to care; however if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

7 The availability and nature of other treatment options Other treatment options for your condition may include: Self-administered, over-the-counter analgesics and rest Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers Hospitalization Surgery If you chose to use one of the above noted other treatment options you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. The risk and dangers attendant to remaining untreated Remaining untreated may allow the formation of adhesion and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE CHECK THE APPROPRIATE BLANK AND SIGN BELOW. I have read ( ) or have had read to me ( ) the above explanation of the chiropractic adjustment and related treatment. I have discussed it with Dr. Roberts and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment. Dated: Dated: Patient Name Doctor s Name Patient Signature Doctor Signature Signature of Parent or Guardian (If a minor)

8 MARK ONLY 1 ANSWER PER SECTION

9 MARK ONLY 1 ANSWER PER SECTION