Patient Intake Form
First Name
Last Name
Phone
*
Email
*
Date of birth
Emergency Contact and Phone number
Sex
Male
Female
Other
How did you hear about us?
Are you seeing the doctor today due to a Worker / Auto Accident Related Injury?
Yes
No
Date of Injury
Address
Street Address
City
State
Country
Enter your country
Postal Code
PLEASE CHECK ALL SYMPTOMS YOU HAVE, EVEN IF THEY DO NOT SEEM RELATED TO YOUR CURRENT PROBLEM:
Headaches
Tension
Depression
Pins and Needles in arms
Cold feet
Neck stiffness
Dizziness
Hot flashes
Constipation
Numbness in fingers
Heartburn
Lights in both eyes
Sleeping problems
Ulcers
Diarrhea
Upper Back Pain
Menstrual Pain
Cold sweats
Lower Back pain
Fainting
Mood swings
Pins and Needles in legs
Middle Back Pain
Neck Pain
Loss of smell
Ringing in ears
Loss of balance
Buzzing in ears
Loss of taste
Nervousness
Numbness in toes
Irritability
Stomach upset
Cold hands
Fever
Problem urinating
Irregular Menstrual's
Leg pain
Arm pain
Foot pain
Hand Pain
Shoulder pain
Elbow Pain
List any medications you are taking
Hayat Chiropractic conforms to the current HIPPA guidelines. You may request a copy of our HIPPA Policy at the front desk. Please initial to indicate you have been made aware of its availability:
The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation.
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Guardian Signature
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TERMS OF ACCEPTANCE When a person seeks Chiropractic care and we accept a person for such care it is essential for both to be working toward the same objective. Chiropractic has only one goal. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent confusion.Adjustment: A specific application of forces to facilitate the body’s correction of the vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spine resulting in nerve dysfunction resulting in the lessening of the body’s innate ability to express its maximum health potential.We do not offer to diagnose or treat any disease other than the vertebral subluxation. However, if we encounter no-‐ chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings we recommend that you seek another healthcare provider.Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribe by others. OUR ONLY PRACTICE OBJECTIVE is to locate, analyze and correct vertebral subluxation by specific adjustments.I authorize release of any information necessary to process my insurance claims and assign and request payment directly to my chiropractor. I understand that Hayat Chiropractic will prepare any necessary forms to assist me in submitting claims to my insurance provider and credit my account when payment is received. However, I clearly understand that all services rendered to me are charged to me and I am responsible for payment unless other arrangements are made. In the event o non-‐payment, it is agreed that I will be responsible for all costs of collections including collection agency fees of 25.0% of the amount owed and / or any related court costs/attorney’s fees. I have read and fully understand the above statements.
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CONSENT TO EVALUATE AND ADJUST A MINORI _______________________________ being the parent or legal guardian of _____________________________________ have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. If you agree, sign below: Type Patients name and guardians Name down below and Sign.
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