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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 Phone: - - Email Address: Occupation: of Birth: List any Allergies: Animals Aspirin Bees Chocolate Dairy Dust Eggs Latex Molds Penicillin Ragweed/Pollen Rubber Seasonal Allergies Shellfish Soaps Wheat X-Ray Dye Other: List any Surgeries with dates: Back Brain Elbow Foot Hip Knee Neck Neurological Shoulder Wrist Other: List ALL Past Medical History conditions: Ankle Pain Arm Pain Arthritis Asthma Back Pain Broken Bones Cancer Chest Pain Depression Diabetes Dizziness Elbow Pain Epilepsy Eye/Vision Problems Fainting Fatigue Foot Pain Genetic Spinal Condition Hand Pain Headaches Hearing Problems Hepatitis High Blood Pressure Hip Pain HIV Jaw Pain Joint Stiffness Knee Pain Leg Pain Menstrual Problems Mid-Back Pain Minor Heart Problem Multiple Sclerosis Neck Pain Neurological Problems Pacemaker Parkinson s Polio Prostate Problems Shoulder Pain Significant Weight Change Spinal Cord Injury Sprain/Strain Stroke/Heart Attack Other: List Medications you are taking: List your Family History: Arthritis Asthma Back Pain Cancer Depression Diabetes Epilepsy Genetic Spinal Condition High Blood Pressure Heart Problems Multiple Sclerosis Neurological Problems Parkinson s Polio Prostate Problems Stroke/Heart Attack Other: 1

Have you had any auto or other accidents? No Yes Describe: of last physical examination: Do you smoke? No Yes Do you drink alcohol? No Yes - how many per day? Do you drink caffeine? No Yes - how many per day? Do you exercise? No Yes (what forms and how often): What is your major complaint? How did this problem begin (falling, lifting, etc.)? How is your condition changing? GETTING BETTER GETTING WORSE NOT CHANGING Have you had this condition in the past? YES - NO What happened? How often do you experience your symptoms? Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Describe the nature of your symptoms: Sharp Dull Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing Other: Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain) 1 2 3 4 5 6 7 8 9 10 How do your symptoms affect your ability to perform daily activities such as working or driving? (0= no effect and 10= can t perform activities) 1 2 3 4 5 6 7 8 9 10 What activities aggravate your condition (working, exercise, etc)? What makes your pain better (ice, heat, massage, etc)? 2

Do you have a secondary complaint? How and when did this problem begin (falling, lifting, etc.)? How is your condition changing? GETTING BETTER GETTING WORSE NOT CHANGING Have you had this condition in the past? YES - NO What happened? How often do you experience your symptoms? Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Describe the nature of your symptoms: Sharp Dull Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing Other: Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain) 1 2 3 4 5 6 7 8 9 10 How do your symptoms affect your ability to perform daily activities such as working or driving? (0= no effect and 10= can t perform activities) 1 2 3 4 5 6 7 8 9 10 What activities aggravate your condition (working, exercise, etc)? What makes your pain better (ice, heat, massage, etc)? How did you find us? I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage. Patient, Parent, or Guardian printed name as signature /s/ Have you ever had chiropractic care? When? Why? Where? When was your last adjustment? 3

FINANCIAL POLICY OF THE FAMILY CHIROPRACTIC CENTER OF SANTA FE Thank you for choosing us as your health provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment.. PAYMENT IS EXPECTED AT TIME OF VISIT UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE The following is a statement of our Financial Policy which we require that you read and sign prior to treatment. REGARDING INSURANCE We will accept assignment of benefits from an insurance policy that is in force at the time of treatment and that covers the treatment provided by this office. You will be responsible for payment at the time of visit for what has been determined to be your portion of the bill. We cannot bill your insurance company unless you provide us with all insurance information. Please understand that your insurance policy is a contract between you and your insurance company. Please be aware that some or perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under your policy. We will do our best to verify and determine your coverage benefits so that you will know in advance just what is covered. The bottom line is that you are ultimately responsible for payment of all charges incurred by you at this office. In the case of managed care plans, we will accept the contracted amounts and you will be responsible for your copayments. You will not be charged the difference between our usual and customary rates and the contracted rates set by the managed care plans. We accept assignment for Medicare claims and will bill them for payment. Your only charge will be to meet your deductible and any co-insurance, if applicable. PERSONAL INJURY POLICY If you have been injured in an auto accident, we will look first to the MedPay part of your auto insurance to pay for services, regardless of who was at fault. If you do not have that coverage, or if you ve been injured in another type of accident, you will either pay for services as they are incurred or contract with a personal injury attorney who will provide us with a Letter of Protection, stating that we will be paid by the attorney after settlement of your case. All fees incurred for treatment at this office will be due and payable following settlement. You will be ultimately responsible for payment of all treatment costs if the attorney fails to do so. MISSED MASSAGE THERAPY APPOINTMENTS Unless canceled 24 hours in advance, our policy is to charge the entire amount due for the massage appointment at the rate of $38.00 per half hour. You will not be charged if an emergency prevents you from keeping your appointment. An emergency is defined as a sudden, urgent, usually unexpected occurrence requiring immediate action. Using our voice mail or email will enable you to leave a message when our office is closed. Thank you for reading and understanding our Financial Policy. Please let us know if you have any questions. I have read the above Financial Policy. I understand and agree to this Financial Policy. /s/ Patient Printed Name as Signature /s/ Guardian/Responsible Party Printed Name as Signature

To Stephen Perlstein, DC/Family Chiropractic Center of Santa Fe, in consideration of your undertaking to treat me, I agree to the following: AUTHORIZATION AND ASSIGNMENT FOR INSURANCE You are authorized to release any information you deem appropriate concerning my physical condition to my insurance company in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequence thereof. I also authorize my insurance company to direct payment of these charges to you as per my policy agreements. DATED: PATIENT: /s/ AUTHORIZATION AND ASSIGNMENT FOR ATTORNEY You are authorized to release any information you deem appropriate concerning my physical condition to my attorney in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequence thereof. I also authorize my attorney to direct payment to you of these charges interimly or at the time of settlement of my case, as per agreement between you and my attorney. DATED: PATIENT: /s/ ACKNOWLEDGMENT AND UNDERSTANDING INSURANCE I hereby acknowledge that I am ultimately responsible for payment of any charges incurred by me at the Family Chiropractic Center of Santa Fe. If my insurance company refuses to pay for charges and/or services for which reimbursement is anticipated, I will pay these charges immediately upon notification. DATED: PATIENT: /s/ ATTORNEY I hereby acknowledge that I am ultimately responsible for payment of any charges incurred by me at the Family Chiropractic Center of Santa Fe. If my attorney is unable to accomplish a satisfactory settlement of my case and only has funds to partially reimburse all charges incurred, or if my attorney refuses to reimburse for all charges incurred, I will pay these charges immediately upon notification. DATED: PATIENT: /s/

FAMILY CHIROPRACTIC CENTER OF SANTA FE 2019 GALISTEO ST. STE M6 SANTA FE, NM 87505 PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION The Family Chiropractic Center of Santa Fe (FCC) is committed to maintaining the privacy of your protected health information (PHI), which includes information about your health condition and the care and treatment you receive from the FCC. This Notice details how your PHI may be used an disclosed to third parties, as well as your rights. CONSENT: The FCC may use and/or disclose your PHI (provided that it first obtains a valid Consent signed by you) for the purposes of treatment (providing it to other physicians by request) and payment (to insurers for billing purposes). NO CONSENT REQUIRED: The FCC may use and/or disclose your PHI without your consent based on the orders of another healthcare provider, in an emergency, as required by law, if there is a barrier to communicating with you, or by court order. FAMILY/FRIENDS: The FCC may disclose your PHI to a family member or close personal friend identified by you. YOUR RIGHTS: You have the right to revoke any consent, request PHI usage restrictions except in an emergency, inspect and copy your PHI, amend your PHI as provided by law, complain to the FCC if your privacy rights have been violated, and receive a copy of this Privacy Notice/Patient Consent. FCC S REQUIREMENTS: The FCC will maintain the privacy and confidentiality of your PHI as by law, reserves the right to change the terms of this notice for maximum PHI effectiveness, and will not retaliate against you for filing a complaint. PATIENT CONSENT: The patient agrees that the above has been read and agreed to, that the FCC can change its privacy practices by law, that the FCC can use and/or disclose my PHI for purposes of treatment or obtaining payment, that I can request that the FCC restrict how my PHI is used and/or disclosed, that this consent is valid for 7 years, that the FCC can refuse to treat me if I refuse to sign below or revoke this consent. This notice is effective as of. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice. /s/ Printed name as Signature If you are a minor, or if you are being represented by another party: /s/ Parent/Guardian/Represenative Printed name as Signature

Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM 87505 505-984-0006 NOTICE REGARDING YOUR SIGNATURE All paper documents that you fill out in this office that constitute part of your patient record will be scanned and entered into the office computer system. All documents that you sign on the Family Chiropractic Center of Santa Fe website with your printed name will be deemed your signature and will make what you are signing legal and binding. The following statements below determine the legality of those signed documents: Photocopies, facsimiles, electronic, or other copies of documents which you have signed shall have the same effect for all purposes as an ink-signed original. All signature lines in all Family Chiropractic Center of Santa Fe documents on the Family Chiropractic Center of Santa Fe website will be preceded with the notation: /s/ which shall signify that the printed name of the signer shall be the legal and binding signature of the signer. By signing below, I certify that I have read and agree with the above statements. /s/ Patient, Parent, or Legal Guardian Signature (Print if online, signature if on paper)

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