New Patient Health History Form

New Patient Health History Form

Personal History

Name

Address

Apt #

City

State

Zip Code

Cellphone Number

Home Phone Number

Work Phone Number

Email

Date of Birth

Age

SS#

Sex

Driver's License #

Occupation

Employer

Status

Name of Emergency Contact

Phone Number

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Accident & Injury Chiropractic will prepare any necessary forms and reports to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Accident & Injury Chiropractic will be credited to my account upon receipt.

However, I clearly understand and agree that all services rendered to me are charged directly to me and I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. In the event that I would like my private health insurance billed, I understand it is my responsibility to notify the doctor’s office of such request.

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 the office and may be released with a written notification and 15 days notice.


Past Health History

Major Surgery/Operation(s)

Major Accident(s) or Fall(s)

Hospitalization(s) (other than above)

Name of your Medical Doctor

Phone Number

Address

Previous Chiropractic Care

Doctor's Name

Date of Last Visit


Current Health Concerns

Height

Current Weight

My current health concerns are from

Major Complaints


How did you hear about our office?

Hear from


Informed consent to Chiropractic Treatment


hereby request and consent to the performance of chiropractic procedures, including a comprehensive exam, diagnostic testing, physical therapy techniques, manual therapy, adjustments or manipulation on me which are recommended by the doctors at Accident & Injury Chiropractic Tacoma Chiropractic and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by or associated with Accident & Injury Chiropractic Tacoma Chiropractic.

Accident & Injury Chiropractic Tacoma Chiropractic, including its doctors and staff, will not be held responsible for any pre-existing medically diagnosed conditions, nor for any medical diagnosis.

I understand that, as with any health care procedure, there are certain complications that may arise during a chiropractic adjustment. Although these complications are rare, they include but are not limited to, muscle sprain/strains, dislocations, fractures, costovertebral strains, and separations. Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke.

I understand that, as with any health care procedure, there are certain complications that may arise during a chiropractic adjustment. Although these complications are rare, they include but are not limited to, muscle sprain/strains, dislocations, fractures, costovertebral strains, and separations.

Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Although our patients are screened for indications that they are candidates for chiropractic
manipulation to the best of our ability, I do not expect the doctor to be able to anticipate all risks and complications during the course of the procedure(s).

Therefore, the doctor based upon the facts then known, will act in the best interest of the patient. I understand that I can terminate at any time, even during the course of any of the chiropractic procedures listed above.

At Accident & Injury Chiropractic Tacoma Chiropractic treatment is often given in an open room concept. Should I need to speak with a doctor at any time in private, I understand that the doctor will provide a room for these conversations. Please feel to ask at any time for such accommodations.

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

  • The right to review the notice prior to signing this consent.

  • The right to object to the use of my health information for directory purposes.

  • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.



Please do not submit any Protected Health Information (PHI).

admin none 8:00 AM - 12:00 PM2:00 PM - 6:00 PM 10:00 AM - 12:00 PM2:00 PM - 6:00 PM 8:00 AM - 12:00 PM2:00 PM - 6:00 PM 8:00 AM - 12:00 PM2:00 PM - 6:00 PM Closed 8:30 AM - 12:00 PM Closed chiropractor # # #