PATIENT DEMOGRAPHICS

HISTORY of COMPLAINT

Please identify the condition(s) that brought you to this office and on a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your complaints.

PATIENT'S NAME: {name}              HR#:  {hrn}                    Date: {dateCompleted93}

PATIENT'S NAME: {name}              HR#:  {hrn}                    Date: {dateCompleted93}

PAST HISTORY

PATIENT'S NAME: {name}              HR#:  {hrn}                    Date: {dateCompleted93}

SOCIAL HISTORY

FAMILY HISTORY

I hereby authorize payment to be made directly to Good Life Family Chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Good Life Family Chiropractic for any and all services I receive at this office.

PATIENT'S NAME: {name}              HR#:  {hrn}                    Date: {dateCompleted93}

Information given to:

I understand that:

• I may inspect or copy the protected health information to be used or disclosed.
• I may revoke this authorization in writing by contacting your office, attention Administrator.
• This authorization is giving (    practice   name   ) the right to discuss my medical information with the one or more people listed above.
• Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient  and no longer be protected by the HIPAA.
• I may refuse to sign this authorization and you will not condition treatment or payment on my providing this authorization (except to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research-related treatment).

REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.

Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at Good Life Family Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. 

REGARDING: X-rays / Imaging Studies

FEMALES ONLY : please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation.

By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.