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New Patient Intake Form

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Welcome to Rockrimmon Chiropractic. We are excited to get to know you.

How did you hear about us?
Were you involved in an automobile accident and that is the reason for your visit(Required)

Patient Information

Patient Name(Required)
MM slash DD slash YYYY
Patient Address(Required)
Patient Status(Required)
Gender(Required)
Patient Email Address(Required)

Emergency Contact

Please let us know who to contact in case of an emergency.

Responsible Party

Please provide contact details of the person financially responsible for this account.
Is patient the responsible party?(Required)
Name(Required)
MM slash DD slash YYYY
Address(Required)
Address for responsible party.
Email Address(Required)
Is this responsible party currently a patient at our office?(Required)

Medical Insurance

Do you have medical insurance?(Required)
Name of Insured(Required)

Accident Insurance

Was the accident your fault?(Required)
Do you have MedPay?(Required)
Our staff can help you determine this if you are not sure.
Have you retained an attorney?(Required)

Note: If you have retained an attorney, you must fill out the “Doctor’s Lien” before undergoing care in this office.

Accident Information

MM slash DD slash YYYY
Time of Accident(Required)
:
What seat were you in?(Required)
Were you wearing a seatbelt?(Required)
Did the police come to the accident site?(Required)
Was a police report filed?(Required)
Were the any witnesses?(Required)
Did your vehicle have Airbags?(Required)
Did the Airbags inflate?(Required)
Was a traffic violation issued?(Required)
How did the accident occur?(Required)
Where was your vehicle struck?(Required)
Check more than one box if appropriate.
Where was the other vehicle struck?(Required)
Check more than one box if appropriate.
Were you aware or surprised by the impact?(Required)
Did any part of your body strike anything in the vehicle?(Required)
What occurred at the moment of impact?(Required)
Check all that apply.
Were you rendered unconscious?(Required)
Did you receive medical attention at the scene of the accident?(Required)
Were you:(Required)
Where did you go immediately following the accident?(Required)
Did you have any physical complaints before the accident?(Required)
Since the accident, have you seen another healthcare provider?(Required)
Include medications prescribed, procedures performed and images taken,(xrays, CT scan, MRI, etc.)
Have you been able to work since the injury?(Required)
If yes, have your work activities been restricted by the accident?(Required)
Is Your Condition getting worse?(Required)
Are your symptoms constant or do they come and go?(Required)
Does your pain travel/radiate from one area to another?(Required)
Check the symptoms that are a result of this accident(Required)

Please indicate your degree of comfort while performing the following activities.

Stretching(Required)
Lying on side(Required)
Lying on back(Required)
Lying on stomach(Required)
Sitting(Required)
Standing(Required)
Walking(Required)
Running(Required)
Sports(Required)
Working(Required)
Lifting(Required)
Bending(Required)
Kneeling(Required)
Pulling(Required)

Current Health Condition

Why are you here today?
Has it occurred before?(Required)
Cause(Required)
Provide any other details that might help us understand your condition.

Past Medical History

Previous Hospitalizations/Surgeries/Serious Illnesses(Required)
Click + to add additional rows.
Description
When
Hospital, City, State
 
Medications(Required)
Include non-prescription. Click + to add additional rows.
Description
Dosage
How often
 
Supplements(Required)
Click + to add additional rows.
Description
Dosage
How often
 
Are you taking medications for acid indigestion?(Required)
Alcohol Use(Required)
Tobacco Use(Required)
Other Drugs(Required)
Past Medical History(Required)
Have you ever had the following? Leave blank if you are uncertain.
Other Disease
List any other diseases you have had. Click + to add more rows.
MM slash DD slash YYYY
Family Medical History(Required)
Click the + to add additional rows.
Relation
Age
Disease
If deceased, cause of death
 

Indicate which of the below you have experienced in the last 1-2 months

Eyes/Ears/Nose/Throat/Respiratory

Eyes/Ears/Nose/Throat/Respiratory(Required)
Muscular/Skeletal
Neurological
General(Required)
Other Conditions
List any other conditions you have experienced in the last 1-2 months. Click + to add more rows.

Assignment of Benefits

Self Pay: It is my responsibility to notify the staff how I will be paying for services rendered. I understand that, if there is no third party (insurance) involved, I am responsible for full payment at the time of service. If a third party does become involved, I understand it is my responsibility to notify the office staff of this change. I further understand it is not the policy of Rockrimmon Chiropractic to bill for services previously rendered.

Insurance/Contract-Services/Third Party: It is my responsibility to know my insurance benefits and plan parameters for chiropractic care, and I will be responsible for contacting my insurance company myself, should I have any questions. I authorize and request my insurance company to make payment directly to Rockrimmon Chiropractic unless other arrangements have been made. We will not become involved in disputes with your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information. Remember, your insurance contract is between you and your insurance company.

Please initial to acknowledge Assignment of Benefits.

Disclosure of Health Care Information (HIPAA)

I understand that my personal health information is private and confidential. The HIPAA Privacy Rule gives individuals the right to request restrictions on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications of that a communication of PHI be made by alternative means. The providers and staff at Rockrimmon Chiropractic, LLC, work hard to ensure the privacy and confidentiality of my personal health information. I understand that providers and staff at Rockrimmon Chiropractic work to disclose to me personal health information to help provide health care, handle billing and information, and to take care of other health operations. I understand that I have the right to ask my provider to limit how my personal information is used or disclosed to carry out treatment, payment, or other health care operations.

Communications(Required)
How would you like for us to communicate with you?
This phone is:(Required)
Message Type:(Required)
Should we leave a detailed message or just a call back number?
Address(Required)
Medical Information Sharing(Required)
I hereby authorize Rockrimmon Chiropractic, LLC to provide clinical information or answer questions regarding my care with the following people. Click + to add additional rows.
Name
Relation
Phone
 
Please initial to acknowledge HIPAA.

Consent to Treat

I hereby request and consent to the performance of therapeutic exercise monitored by a rehabilitation technician, chiropractic manipulation and manual therapy techniques and other chiropractic procedures, including various modes of physical therapeutic modalities and procedures and diagnostic X-rays, where warranted, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed below.

I can discuss with the doctor of chiropractic named below the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment and diagnostic services including but not limited to:

Adjustments: increased discomfort, fractures, disc injuries, strokes, dislocations and sprains.

*The primary techniques used by the doctors at Rockrimmon Chiropractic virtually eliminate the risk of fracture, dislocations, stroke, and disc injury – but we still have to say it.

Therapeutic Modalities and procedures: additional pain and discomfort.

Radiographs: ionizing radiation can be harmful to a fetus for those who are pregnant or might be pregnant.

Lab Draws: bleeding at site of draw, bruising, nausea and loss of consciousness I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. The doctor named below has additionally explained the risks associated with my refusal of treatment.

I understand that if I request a private consultation with the doctor to discuss personal health matters, upon my request, this private room with the doctor and a staff member will be provided.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Please initial to acknowledge Consent to Treat.

Consent to evaluate and adjust a minor child

I, being the parent or legal guardian of the patient have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. *In case of a medical emergency, if the patient is of school age 15+, is ok to treat in my absence.

Please initial to acknowledge consent to evaluate and adjust a minor child.
Use your finger or mouse to sign.