chiropractic Bringing Out The Best In You!
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- Winfred Payne
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1 chiropractic Bringing Out The Best In You! New Patient Welcome To Our Office SHAWN P. NEVILLE, DC Kennedy Chiropractic 4140 Crain Highway Waldorf MD drneville.com Date Name Preferred name Address City/State/Zip Phone #s (home) (cell) address SS # Birthdate Age Occupation Employer Is it okay to contact you at work? m no m yes Work # Marital status m single m married m separated m divorced m widowed Spouse/Partner Name: Phone #(s) Is it okay to text you? m no m yes Favorite hobbies or interests Emergency contact: Name Relationship Phone #(s) What Brings You Here? Have you ever had chiropractic care before? m no m yes If yes, please tell us who Phone # Were you pleased with your care? m no m yes How did you find out about our office? Is this appointment related to m work m sports m auto m personal injury m other When did the incident occur? Attorney (if applicable) Phone # Are you receiving care from other health professionals? m no m yes If yes, please name them and their specialty Please list any drugs or medications you are taking Please list any vitamins/herbs/homeopathics/other you are taking Are you pregnant? m no m yes If yes, what month?
2 New Patient: Welcome To Our Office 2 Current Health What are your pressing health concerns? For how long? Is it m getting worse m improving m intermittent m constant m can t say Please draw the location of your pain or discomfort on the images below. Use the symbols shown to represent the pain you are experiencing. D=Dull B=Burning N=Numb S=Stabbing/Cutting T=Tinging/Cutting C=Cramping Do you have m pain m numbness m tingling m aches Is your pain m sharp m dull m throbbing m constant m intermittent Are your symptoms affected by m sitting m standing m walking m bending m lying down m weather m other Please explain Do you feel m cramps m burning m stiffness m swelling m other Please explain Do your symptoms interfere with m work m sleep m day-to-day activities m play m other On a scale of 1-10 (1 least, 10 most), please rate: The severity of your symptoms
3 Health History New Patient: Welcome To Our Office 3
4 New Patient: Welcome To Our Office 4 What Do You Know About Chiropractic? In your own words, what do chiropractors do? Do you know what a subluxation is? m no m yes If yes, please describe Do any friends or relatives see chiropractors: m no m yes If yes, do they use chiropractic for m health maintenance/optimization m health problems m both Are you seeking chiropractic for m health maintenance/optimization m health problems m both What would you like to gain from chiropractic care? Are there other health concerns or anything else you d like us to know about you? m no m yes If yes, please tell us Financial Responsibility Who is responsible for payment? Insurance co. Phone # ID # Group # Subscribers s name Phone # Relation Subscriber s employer Subscribers s SS # Subscriber s birthdate The above is accurate to the best of my knowledge. (signature) (date) I, parent/guardian, give permission for minor s care. (signature) (date)
5 PATIENT HIPAA CONSENT FORM Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to define situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and disclosed. Date: _ Print Patient Name: Signature:. Relationship to Patient: FINANCIAL POLICY Our goal is to provide the highest quality of healthcare possible for our patients. In order to achieve this goal, we need your commitment as well. We urge our patients to follow the doctor's recommendations for care. Please keep your appointments as scheduled or call our office within 24 hours to make any changes. In order to attain the level of achievement we both desire, care must be followed as outlined. I hereby authorize Kennedy Chiropractic/Dr. Shawn P. Neville to release any information deemed appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred by me. I authorize the direct payment to Kennedy Chiropractic/Dr. Shawn P. Neville of any sum I now or hereafter owe by my attorney out of settlement of my case, and by any insurance company obligated to me or Kennedy Chiropractic/Dr. Shawn P. Neville based in whole or in part upon the charges made for services received. I hereby appoint Kennedy Chiropractic/Dr. Shawn P. Neville authority to endorse and cash checks, drafts, or money orders made payable to the undersigned or as co-payee with this clinic for payments due for services rendered on behalf of the undersigned by Kennedy Chiropractic/Dr. Shawn P. Neville. In order to file your claims in a timely manner, we need current and accurate insurance information for you and your dependents. We will do our best to confirm eligibility and level of insurance coverage for care; however, it is ultimately YOUR responsibility to know your own insurance benefits in relation to what your insurance covers and what it does not. Should your insurance carrier determine that any or all of our services are inelgibile for payment, you will be billed directly for those services. Late payment for non-coverage, deductible and co-payment may be subject to an 18% annual finance charge, which will be added monthly to that account. Advanced Beneficiary Notice of NON-Coverage (ABN). Your health insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect your health insurance will not pay for items and services such as your initial visit and any chiropractic care deemed maintenance or wellness care by your carrier (as well as other items that may arise in the future). Signing below signifies that you want these items and services, but understand that they will not be billed to your insurance company. Therefore, you are responsible for payment and cannot appeal to your insurance carrier as they were not submitted and/or billed to them. This notice gives our opinion, not an official Medicare or other insurance carrier. If you have any questions, ask. Date: _ Signature: _ AUTHORIZATION FOR CARE I hereby authorize doctors and staff at Kennedy Chiropractic to treat my condition as deemed appropriate. At Kennedy Chiropractic, we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctor/clinic will not be held responsible for any pre-existing medical conditions. I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any staff member of Kennedy Chiropractic responsible for any errors or omissions that I may have made in the completion of this form. Chiropractic, as well as all other types of health care, is associated with potential risks in the delivery of treatment. While chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you. Date: Signature: _
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
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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
Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX (972)
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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
Date of Birth: / / Address: Social Security #: - - City: State: Zip: Sex (circle one): M F Address: Cell Phone: ( ) Home: ( ) Work: ( )
400 Lem Morrison Drive Auburn University, AL 36849 Phone: 334-844-7651 Fax: 334-844-6245 PATIENT INFORMATION Name:_ Last First Middle Date of Birth: / / Address: Social Security #: - - City: State: Zip:
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:
Policies and information:
Policies and information: Basic Policies: Please be on time for your appointments. If you are late for your scheduled appointment, there is a chance that you will be rescheduled. We require at least 24
entral Chiropractic Center
Patient Information Date: Name Sex M F Birthdate last middle initial first Address street/p.o. box city state zip Marital Status Single Married Widowed Separated Divorced Social Security # Occupation Primary
VELOCITY CHIROPRACTIC AND SPORTS REHAB Patient Information Date Name Preferred Name SS# DOB Age M ale Female Address City, State, Zip Cell Phone HomePhone EmailAddress --------- --------- --------- Referred
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ 85260 480-443-2584 www.wellnessdoc.com Date Home Phone Work Phone Cell # Patient e-mail: Last Name First Name Street Address City
WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( )
WELCOME TO OUR OFFICE Patient s Name: Today s Date: First Middle Last Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( ) Email: Personal Work DOB: Age: SSN#: Ethnic Background:
Patient Health Summary
Patient Health Summary Patient Name: Birthdate: / / Sex: M F Address: City: State: Zip: CIRCLE which telephone # to leave appointment reminders or health related messages: Home: Work: Cell: Do you give
PREPARATION FOR YOUR APPOINTMENT
Welcome to SOL Santa Cruz, and thank you for choosing Christopher Taquino, DPT as your Physical Therapy provider. Our entire staff is committed to serving you and making your rehabilitation experience
INSURANCE INFORMATION
PATIENT NAME: ADDRESS: CITY: STATE/ZIP CODE: HOME PHONE NUMBER: CELL PHONE NUMBER: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: GENDER: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMPLOYER NAME:
New Patient Registration Form
New Patient Registration Form Patient Information Name: (First) (Middle) (Last) SSN: of Birth / / Sex: Male Female Street Address (or PO Box): City: State: Zip: Marital Status: Single Married Divorced
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:
Nicholas Southworth, D.C.
Always Active, Always Improving Nicholas Southworth, D.C. PATIENT INFO Patient Name: Male [] Female [] Birthdate: / / Age: SS#: - - DL # Home Address City/State/ZIP Home Phone: ( ) Cell Phone: ( ) Would
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
York Chiropractic Clinic Registration and History
York Chiropractic Clinic Registration and History PATIENT INFORMATION Date _ First Name Last Name Address City State Zip Code Sex Male Female Date of Birth: Home Phone ( ) Cell Phone ( ) Best place to
NEW PATIENT REGISTRATION FORM
DATE APPOINTMENT WITH PATIENT INFORMATION NEW PATIENT REGISTRATION FORM PATIENT'S LAST NAME/Apellido Del Paciente FIRST NAME/Primer Nombre DOB AGE/Edad MR # SOCIAL SECURITY # STREET ADDRESS/Direccion APT.
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: