New Patient Forms - Online - Tucker Chiropractic

CONFIDENTIAL PATIENT INFORMATION

This information is confidential. If we do not sincerely believe your problem will respond favorably, we will not be able to accept your case. We will refer you to disciplines that we believe will help you. In order for us to understand your health problems, please complete this form neatly, accurately, and completely. Thank You.

Full Name *

Birth date *

Age *

Sex *

M
F

Address

City *

State *

Zip code

Phone: Home *

Cell *

E-mail *

Status (check one): *

Single
Married
Widowed
Separated

Children: #

Ages

Occupation

Employer

Supervisor

Work Address

Work Phone *

Spouse / Parent *

Birth date *

In case of Emergency contact: *

Relation

Phone *

Medical Doctor

Phone *

Doctor’s address

How did you hear about our office?

Have you ever been to a Chiropractor?

Y
N

Last visit date

Describe Results:

LIST COMPLAINTS:

SYMPTOMS ARE WORSE: *

AM
MIDDAY
PM

ARE THERE ANY ACTIVITIES THAT YOUR CONDITION INTERFERES WITH? GIVE DETAILS:

IS YOUR CONDITION DUE TO AN ACCIDENT / FALL / ILLNESS / OTHER? GIVE DETAILS:

List other Doctor(s) consulted for present complaints and injuries:

Name *

Type of Doctor

When consulted

Treatments / x-rays

Diagnosis

How long did you see the Doctor?

How frequently?

Results:

Patient Name *

Name *

Type of Doctor

When consulted

Treatments / x-rays

Diagnosis

How long did you see the Doctor?

How frequently?

Results: *

PAST MEDICAL HISTORY

List any medical conditions you have ever had / have and dates: *

List any surgeries you have had and give dates: *

Broken Bones: Which / When / Remarks:

List other accidents or serious falls: (auto, work home; leisure, sports, other) What / When / Treatment / Results:

For Women: Are you pregnant?

Yes
No

First date of last menstrual cycle

List all medications you are now taking:

List all vitamins and supplements you are now taking:

Do you have a back brace?

Yes
No

Is your pillow Comfortable?

Yes
No

How do you sleep?

stomach
side
back

How often do you use alcohol/tobacco? *

INSURANCE INFORMATION

Insurance company *

ID# *

Subscriber's name

Birth date

Address

City

State

Zip

SS#

ASSIGNMENTANDRELEASE

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that the Doctor's Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable.

I here by authorize the Doctor to treat my condition as he or she deems appropriate. It is understood and agreed the amount paid the Doctor, for X-rays, is for examination only and the X-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.

Patient's Signature *

Date *

Consent to Treat a Minor

Date

Guardian or Spouse's Signature of Authorizing Care

Date

Consent Agreement

Consent to the Use and / or Disclosure of Health Information for Treatment,Payment or Healthcare Operations.

I *

understand that as part of my treatment and care, this results, diagnoses, treatment and any plans for future care and/or treatment. I understand that this information serves as:
1. A basis for planning my care and treatment.
2. A means of communication among the many healthcare professionals who contribute to my care.
3. A source of information for applying my diagnosis and surgical information to my bill.
4. A means by which a third-party payer can verify that services billed were actually provided.
5. A tool for routine healthcare operations such as assessing quality and reviewing the competence of our
6. To call you and remind you of appointments.
7. To discuss your test results and treatment plan.

I understood if i wish to obtain a copy of the office's Nootice of Privacy Practices, that provides a more complete description of information uses and/or disclosures, one will be made available for me. I understand that i have a right to review the notice prior to signing this consent. I understand that this office reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised Notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that this office is not required to agree to yjr restrictions requested. I understand that i may revoke this consent in writing, except that for actions taken by this office in relying on such information.

I understand and authorize, that at times it will be necessary for this office to call my home or place of business and leave messages on answering machines, voicemail or E-mail.

I fully understand and accept the terms of this consent.

Patient’s Signature *

Date *

Patient Name *

Date *