Avisechiropractic.com - New Patient Intake

Confidential Health History Questionnaire
Today's Date:

MonthDayYear
Date
Legal Full Name:

First NameLast Name
Name you prefer:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Home
Please enter a valid phone number.Format: (000) 000-0000.
Phone Cell
Please enter a valid phone number.Format: (000) 000-0000.
Phone Work
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HomeWorkCell
Birthdate:

MonthDayYear
Date
SSN:
Age:
Sex:
SingleMarriedWidowedDivorced
Spouse Name:
# of Children:
Email Address:
example@example.com
Whom may we thank for referring you to the office?
Emergency Contact:
Relationship:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Your Employer:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Job Title:
Thank You for consulting our office. We consider it an honor to have a chance to be part of your health care team.

Terms of Acceptance
At Avise Family Chiropractic we offer chiropractic care to treat vertebral subluxations. We do not diagnose or treat any disease or condition other than subluxations. However if during the course of an examination we encounter non-chiropractic or unusual findings, we will advise you.
Office Policy

Keeping your appointments is vital to getting you back on track. We do not charge for missed chiropractic appointments, but we ask that you give us as much notice as possible if you are unable to make it. We also ask that you reschedule immediately so that you maintain your progress. Initial*

We serve patients in the following order: Scheduled appointments, call-ins, walk-ins. You are welcome to walk-in once you are an established patient, however to minimize wait times, please call ahead to schedule. Initial*
Financial Policy

Insurance benefits quoted are not a guarantee of payment by my insurance company. I understand that I am responsible for all charges incurred with my provider. initial*

All co-payments, deductible, and non-insurance covered chargers must be paid at time of service. Our Fortis software saves payment information to the patient's account vault. Payments will run by account vault unless otherwise requested.

I have read and understand the Terms of Acceptance, Office, and Financial Policies and agree to the above terms. I also understand that the practice may amend the terms from time to time.
Signature*

Clear
Date*

MonthDayYear
Date
Treatment of a Minor

For all services rendered to a minor, we will look to an adult to accompany the patient and for payment of any fees for services. I, Name , am the parent or legal guardian of . I certify that I have read and fully understand the terms above and hereby grant permission for my child to receive chiropractic care.
Signature:

Clear
Date:

MonthDayYear
Date

AUTHORIZATION FOR HIPAA
Our Notice of Privacy providers information about how we may use or disclose protected health information. We are happy to provide you with a copy of the HIPAA privacy Act.

The notice contains a patient's right section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor the agreement.

The HIPAA (Health Insurance Portability and Accountability Act of 1996)law allows for the information for treatment, payment, or health operations.

By signing this form, I understand that:

Chiropractic services may be delivered in an open door room described in the office privacy notice.
The practice may contact you by phone, text or email to remind you of appointments or upcoming events.
The practice reserves the right to change the privacy policy as allowed by the law.
The practice has the right to restrict the use of the information but the practice doesn;t have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
YESNO
If YES, please name the members allowed:*
This consent was signed by:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Rows	Past	Now	Doctor's Comments:
General Health (e.g. Fatigue, Stressed)
Mind (e.g. Depression, Anxiety)
Neurologic (e.g. Stroke, Seizure, H.A.)
Visual (e.g. Blurred Vision, Double)
ENT/Mouth (e.g. Ringing in Ears, Jaw Pain)
Hearth (e.g. Heart attack, Pacemaker)
Breathing (e.g. Asthma, Short of breath)
GI (e.g. Vomiting, Diarrhea, Ulcer)
GU (e.g. Incontinence, Sexual Dis.)
Endocrine (e.g. Diabetes, Thyroid Disease)
Sinus Immune (e.g. Congestion, Freq. Cold/Flu)
Musculoskeletal (e.g. Neck, Mid, Low Back pain)

Confidential Health History Questionnaire

Health History

REVIEW OF SYSTEMS:

Terms of Acceptance

AUTHORIZATION FOR HIPAA