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  • Patient Information

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  • Spouse Information

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  • Employment Information

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
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  • Describe Your Symptoms

  • Numbness

    10 being the worst

  • Burning

    10 being the worst

  • Stabbing

    10 being the worst

  • Tingling

    10 being the worst

  • Dull Ache

    10 being the worst
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  • Recent Symptoms/Pain

  • My pain interferes with Daily Activities

    Choose the effect of the current condition of your ability to perform the following tasks
    Check the one that best describes your job describes your job description.
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  • Physical Status

  • Section Break

  • Section Break

  • Age Gender Actions
       
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    There are no Children.

    Maximum number of children reached.

  • Date Format: MM slash DD slash YYYY

  • Past Surgeries and/or Injuries

  • Reason Current Status Actions
       
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    There are no Surgeries/Hospitalizations.

    Maximum number of surgeries/hospitalizations reached.

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  • Social History

    Check all that apply to you

  • Family History

    Check all that apply

  • Review of Systems

    Check the box if you have had trouble with any of the following.
  • Please Choose
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  • Medication, Vitamin, Allergy List

  • Medication/Vitamin Name Dosage (mg) Frequency Actions
         
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    There are no Medications.

    Maximum number of medications reached.

  • Medication Adverse Reaction(s) Actions
       
    • Edit
    • Delete
    There are no Allergic Reactions.

    Maximum number of allergic reactions reached.

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  • Acknowledgement of Office Policies

  • The following are Chiro-Associates policies governing appointment scheduling, payment terms, and information release. Please read each section carefully, initial, and sign at the bottom. Be sure to ask any questions you might have before signing the document.
  • Appointment Scheduling - At Chiro-Associates, we are glad to accept insurance assignment on your behalf in handling your health insurance, personal injury, or worker’s compensation claim. However, in order to help ensure that your insurance company pays for the services you receive, it is important that you adhere to the recommended care program. This means that if you miss several appointments without notifying our office (emergencies considered), you may be dismissed from care and your file may be closed. Please remember that your appointment time is reserved for you and no one else. Our office confirms your appointment and our answering machine is available after hours. In the circumstance where you do not attend your appointment or 24 hours notice is NOT given for a canceled appointment; please be advised that you may be held financially responsible for a no show/cancellation fee. We only treat those patients who want to get well. If you don’t attend your appointment, everyone misses out: you, another patient who could have taken that spot, and the doctor. It is our office policy to charge a No Show/Cancellation (without 24-hour notice) FEE OF $35 per episode. We certainly understand that things happen, but everyone will be happier when you call and reschedule in advance. So, if you'd like to reschedule a confirmed appointment “NO PROBLEM”; just let us know 24 hours in advance. Our staff will be happy to answer any further questions regarding this policy.
  • Notice of Insurance Requests - It is not unusual for health insurance companies to request documentation from patients concerning treatment. The information you provide is used to determine whether your treatment with our office was due to an automobile accident or a work-related incident (injury). Please understand that it is your responsibility to respond to any insurance requests regarding your treatment received at Chiro-Associates. An appropriate and timely response to these requests is necessary. Note: Failure to respond will result in your claims not getting processed and you the patient will become financially responsible for services
  • Private Health Insurance/Non-Covered Service Waiver - I understand that I am financially responsible for all costs associated with any services provided at Chiro-Associates that are NOT covered by my health insurance plan. I am financially responsible for any deductibles, co-pays/co-insurance, and services rendered that are the exclusion of benefits. (These charges include services and procedures; not covered under my health insurance plan, not a covered benefit under my plan, or doctor is not contracted to perform/provide services/procedure (modalities/therapies.) By signing this statement, I understand that I agree to pay for all services provided which are not covered by my insurance plan.
  • Acknowledgment and Understanding - I the undersigned, agree to pay the full amount of the charges should my condition be such that it is not covered by my insurance policy, or if, for any reason, the insurance company and/or my attorney refuses to pay my balance at this office. Please be aware that health insurance reimbursements for only medically necessary injuries/conditions.
  • Patient Requests for Records - I authorize the release of all “PHI”, medical, hospital, or surgical records pertinent to my case, including but not limited to exams, special tests, x-rays, MRIs, or lab results to Chiro-Associates.
  • Privacy Practices and HIPAA Regulations - I acknowledge that I have received, carefully read, and understand the Notice of Privacy Practices and been given the opportunity for explanation regarding all HIPAA regulations.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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