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Birdsall Chiropractic

Hand & Foot Clinic

Take your Life Back

INTAKE FORM

Date: *

Last Name *

First Name *

Date of birth *

Preferred to be called

Spouse’s Name

Email *

Address *

City *

State *

Postal code *

Home number *

Phone number

Occupation (Current / Previous)

Retired

Yes

How Did You Hear About Us? *

EMERGENCY NOTIFICATION INFORMATION

In the event of an emergency, whom should we contact? *

Name *

Relation to patient *

Home Number *

Cellphone Number *

Work Number

PERSONAL HEALTH HISTORY

Do you smoke? *

Yes

Do you drink? *

Yes

Do you exercise regularly? *

Yes

Describe what type of exercise and how often *

Height *

Weight *

Have you been hospitalized? *

Yes

If yes, explain

List any surgeries and dates

Have you been deemed disabled? *

Yes

Date

Are you still able to work? *

Yes

PRESENT HEALTH CONDITIONS

Please check by any that you have been diagnosed with.

Cervical

Stenosis

Herniated Disc

Degenerative Discs

Lumbar

Stenosis

Herniated Disc

Degenerative Discs

Thoracic

Stenosis

Herniated Disc

Degenerative Discs

Leg

Numbness

Tingling

Burning

Pain

Do you use a:

Walker

Wheel Chair

Cane

Other

Hand

Numbness

Tingling

Burning

Pain

Arm

Numbness

Tingling

Burning

Pain

Have you had a:

Cervical MRI

Lumbar MRI

Doppler Study

NCV / EMG

Neurological Disorders

Parkinson’s

Alzheimer’s

Multiple Sclerosis

Are you able to:

FAMILY HEALTH HISTORY

Please MARK next to any condition that someone in your family HAS or has HAD

ADDITIONAL SYMPTOM INFORMATION

What do you think is causing your problem? *

Have your symptoms *

Improved

Worsened

Stayed the Same

List anything that makes your condition worse *

List anything that makes your condition better *

Is there a certain time of day any of these problems are better or worse? *

Authorization for Examination and/or Treatment

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand the doctor’s office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any account authorized to be paid directly to the doctor’s office will be credited to any account or receipt. However, I clearly understand and agree that all services rendered are charged directly to me and that 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 to me will be immediately due and payable. When billing my insurance company for personal injury claims, I give permission for the insurance company to pay provider directly for any billed services.

I hereby authorize the doctor to examine and treat any condition as he deems appropriate and I give authority to these procedures to be performed. It is understood and agreed the amount paid to the doctor for x-rays is for examination only and will remain the property of this office, being on file where they may be seen at any time while a patient at this office. The patient also agrees that he/she is responsible for all bills incurred at this office. The doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

Notice to our new patients: Full payment for services rendered is due at the end of each visit. If for any reason this request cannot be met, arrangements should be made in advance before seeing the doctor.

Patient Signature *

Clear

Date *

Consent for Treatment of a Minor

(I) , the undersigned, parent(s)/person having legal custody/legal guardianship of , a minor, do hereby authorize and give consent to Birdsall Chiropractic Hand & Foot Clinic for any x-ray examination and chiropractic diagnosis or treatment, which is deemed advisable by a licensed chiropractor, be rendered under the general or special supervision of any licensed chiropractor. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required but is given to provide authority to the above described agent(s) to give specific consent to any and all such diagnosis and treatment which chiropractor, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable. This authorization shall remain effective until revoked in writing delivered to Birdsall Chiropractic Hand & Foot Clinic.

Parent/Guardian Signature

Clear

Date

Declaration of Agreement Regarding Missed or Cancelled Appointments

Please understand that when an appointment is scheduled for you, a time is set aside and reserved for you on the master schedule. Failure to cancel without appropriate notice prevents us from filling the vacancies on our schedule and often prevents people in need from receiving desired services in a timely manner. Therefore:

1. It is my responsibility to notify 24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment

2. I will be charged $25.00 in the event that I miss an appointment and fail to cancel two (2) hours prior to the scheduled appointment.

Patient initials *

Clear

Consent for Medical Records Release

This is a confidential record of your medical history and pertinent personal information. Per confirmed consent the doctor will have the ability to discuss medical information with the patient’s other doctors. Copies of this record can only be released by your written authorization.

Patient initials *

Clear

Out of Network Agreement

I understand that Birdsall Chiropractic Hand & Foot Clinic is an "out of network" provider and I am responsible for payments at time of service. I also understand that I am able to obtain, upon request all the information and paperwork needed in order to submit to my insurance to receive reimbursement based on the agreement I have with them.

Disclaimer

Appointment Confirmation *

$ 25

Other amount

We require a $25 payment to reserve your appointment time. Our cancellation policy reqires 24 hour notice of cancelation for new patients or a $25 fee is charged. When you show up for your appointment this $25 will go toward your visit.