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. Date Name Social Security # Address City State Zip Code Birth Date Home Phone # Cell Phone # Work Phone # Preferred contact number: Home/Cell/Work Would you like to receive a text message / reminding you of an upcoming appointment? Y or N Employer May we contact you at work Y or N Single Married Divorced Widowed Minor # of Children Emergency Contact Phone # Whom can we thank for referring you? 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 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 insurance card. Health Questionnaire Reason for today s visit: When did your symptoms begin? How frequent are your symptoms? Constant Frequent Intermittent Occasional When are your symptoms worse? Morning Afternoon Evening No Change Weather Change What relieves your symptoms? What activities are limited by your symptoms? Other doctors seen for this condition: Have you ever been to a chiropractor before? Y or N If yes, when? Is this condition due to an accident? Y or N Date: Auto Work Other (For Females Only) Are you pregnant? Y or N Date of last menstrual cycle: How many days of the week do you exercise? Current height: Weight: How would you rate your diet? Poor Fair Good Excellent Do you consume alcohol? Y or N If yes, on average how many drinks/week? Indicate if an immediate family member has had any of the following: Rheumatoid Arthritis Heart Problems Diabetes Cancer Other Previous Surgeries (please list procedure and year): List all Prescription and Over-the-Counter Medications that you are taking: List all Nutritional and Herbal Supplements that you are taking: What do you hope to get from your visit/treatment (select all that apply): Reduce Symptoms Explanation of Condition/Treatment Resume/Increase Activities Diet and Nutritional Advice Exercise Instruction Preventing Symptoms in the Future
3 For each of the conditions listed below, place a check in the Past column if you have had the condition in the past. If you presently have a condition listed below, place a check in the Present column. Past Present Past Present Past Present Headaches High Blood Pressure Allergies Jaw Pain Heart Attack Asthma Neck Pain Chest Pains Epilepsy Mid Back Pain Stroke Depression Low Back Pain High Cholesterol Eczema/rash Shoulder Pain Kidney Disorders Sinusitis Elbow/Arm Pain Bladder Infections Poor Sleep Wrist/Hand Pain Yeast Infections Hip/Upper Leg Pain Prostate Problems Knee/Lower Leg Pain Diarrhea/Constipation Ankle/Foot Pain Abnormal Weight Gain/Loss Trouble Walking Ulcer Joint Swelling Liver Disorders Joint Stiffness Gallbladder Disorders Numbness/Tingling Cancer General Fatique Diabetes Muscular Incoordination HIV/AIDS Visual Disturbances Tobacco Product Use Dizziness Drug/Alcohol Dependence Thank you for taking the time to fill out our health questionnaire. It will help us to better serve you!
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
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,
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: ( )
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
First Name MI Last Name. Address. City State ZIP. Phone (H) (W) (Cell) (Please circle the preferred contact number) Address
Date of Birth Social Security Number - - First Name MI Last Name Address City State ZIP Phone (H) (W) (Cell) (Please circle the preferred contact number) Email Address Occupation Full Time/Part Time Employer
1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND (701)
AKER CHIROPRACTIC Dr. JaNyne Aker, D.C. 1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND 58078 (701) 356-4900 PATIENT INFORMATION: TODAY S DATE: / / Name First MI Last Address City
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:
WALL FAMILY CHIROPRACTIC CENTER
WALL FAMILY CHIROPRACTIC CENTER Dr. Michael L. Wall, D.C. 13412 Pacific Avenue Tacoma, WA, 98444 Office: (253) 531-5242 Fax: 253-537-7293 About the Patient Name: Address: City: State: Zip: Home Phone:
Date. D Light D Moderate D Strenuous
FAMILY CHIROPRACTIC CARE PATIENT HEALTH QUESTIONNAIRE Patient Name What type of regular exercise do you perform? D None Date D Light D Moderate D Strenuous What are your overall health goals? D Weight
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
ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE
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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
Demographic Information
Demographic Information Patient Name: Mailing Address: City: State: Zip Code: Home Phone: OK to Leave Message: Brief Extended Cell Phone: OK to Leave Message: Brief Extended Work Phone: OK to Leave Message:
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)
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Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
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PATIENT REGISTRATION
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W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By
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LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice.
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**EHR Information (DO NOT SKIP)** Marital status: Married Single Widowed Divorced Separated
Electronic Health Records Intake Form Please Print Name Date of Birth Social Security # Mailing Address City State Zip Code Verizon AT&T Sprint T-Mobile Metro PCS Home # Cell # Cricket Tracfone Other Preferred
*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
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Ronald M. Yarab, Jr., M.D. Michael T. Engle, M.D. Sean T. McGrath, M.D. Patient s First Name: M.I. Last: Mr. Mrs. Miss Ms. Marital status: (circle one) Single / Married / Divorced Separated
Saline Heart Group, PA
www.salineheartgroup.com Patient Account # Date: Patient Information In order for us to provide you with the best possible care, please fill out these forms as completely and accurately as possible. Last
PHYSICAL THERAPY CENTRAL
PHYSICAL THERAPY CENTRAL PATIENT INFORMATION Patient Name: Address: City: State: Zip: Employer: Birthdate: Age: Home Phone: Cell Phone: Work Phone: Preferred Contact Method for Appointment Reminders: Home
Welcome to BetterBody Solutions
Welcome to BetterBody Solutions Please fill out our history forms completely and accurately to the best of your ability so that we can quickly get you on the road to health. We appreciate you choosing
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
4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB):
If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
AMELIA A. PARÉ, M.D. PATIENT REGISTRATION Date of visit: PATIENT INFORMATION (PLEASE PRINT) Name: Date of Birth: Age: Male Female Race Social Security #: Marital Status: Single Married Divorced Widowed
PATIENT RECORD Please fill out completely. Thank you. Referring Physician. Last Name Legal First Name MI
PATIENT RECORD Please fill out completely. Thank you Date Referring Physician Last Name Legal First Name MI Mailing Address City ST. Zip Home Phone CellPhone Sex Birth Date Social Security # Email address:
Advanced PT, LLC 200 W Douglas Ave, Ste 1040 Wichita, KS (866)
200 W Douglas Ave, Ste 1040 Wichita, KS 67202 (866) 412-5554 Welcome to Advanced PT, LLC. We are honored that you have chosen us as your therapy provider. Our goal is to provide the highest quality of
Ravi Yalamanchili M.D, P.A. Patient Registration / Information Sheet Last Name: M.I. Sex: Female Male First Name: Marital Status:
We do not Accept Checks Ravi Yalamanchili M.D, P.A. 141 Thomas Johnson Drive, Suite 200 Frederick, MD 21702 Phone 301-846-0100 Fax 301-846-0244 Please Print Patient Registration / Information Sheet Last
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):
Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX phone 102 E Young St Llano, TX phone
Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX 78611 512-756-2131 phone 102 E Young St Llano, TX 78643 325-247-2020 phone PATIENT REGISTRATION Patient s Name Today's Date Mailing Address City
CENTRAL OHIO PLASTIC SURGERY, INC. (740)
(740) 653-5064 Patient s Name Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Last First Middle Nickname Address Street & Apt # City State Zip Home
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
Prairie Life Chiropractic 1224 S. Main Ave. Sioux Center, IA 51250
Patient Information Name Birth Date Guardian s Name (If applicable) Address City State Zip Home Phone ( ) Cell ( ) Email Sex: Age SS# Race: Ethnicity: Occupation Employer Employer City Employer Phone(
Registration Information
Nevada Spine Center, LLC Registration Information Date Chart# D.O.B 10195 W. Twain Avenue Suite B Las Vegas, NV 89147 Patient Name SSN: Employer Drivers License # Required by the State of Florida Agency
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
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
PATIENT REGISTRATION FORM Account #:
PATIENT REGISTRATION FORM Account #: All forms must be completed and signed prior to treatment. GENERAL INFORMATION Patient Name: First Middle Last Address: Home Phone No: Work Phone No: Cell Phone No: