Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs. Please be sure to complete all sections, including signature and approvals.

Health Insurance/Payment Information *

I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office 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 that I am 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.

Informed Consent *

The Nature of Chiropractic Treatment: Chiropractors commonly use their hands or a mechanical device in order to restore mobility and function to joints that are not moving or functioning optimally. For many patients, certain therapies or exercises may also be used to maximize healing and pain relief. I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease.

Possible Risks: The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give a chiropractic adjustment, or other treatment, if he/she is aware that such care may cause problems. It is the patient’s responsibility to inform the doctor of any known pathological defects, illnesses, or deformities which would not otherwise come to the attention of the doctor. The most common adverse effects are minor and temporary and include stiffness or soreness after the first few days of treatment (similar to starting a new exercise regimen). Other rare but potential complications include muscular strain, fractures of bone, injury to intervertebral discs, nerves or spinal cord, or stroke/cerebrovascular injury (estimated to be less than 1 in 2 million to 5.8 million cervical manipulations). Complications from therapies used in addition to your adjustment are rare but may cause skin irritation, burns, soreness, bruising, or other minor complications.

Risks of remaining untreated: Delay of treatment often results in further deterioration of the condition and may lead to chronic pain and disability, or surgery.

I have read the above explanation of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment.