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Adult Personal Health History
Welcome to Nexus Family Chiropractic. We're so glad you're here...click below to begin your journey
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  • 13
    Please list your BEST number for us to contact you
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    Please list the names and ages of your children.
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  • 27
    You deserve to be healthy. When you were conceived, you were given the blue-prints, intelligence, and systems to live an active, healthy, long life. Unfortunately, the natural expression of your health can be interfered with. Through your examination and through your involvement in chiropractic care, we will work to remove these interferences and keep them out of your life, so that you can heal quickly and live the quality lifestyle you deserve.
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  • 73
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  • 74
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  • 75
    As a result of my chiropractic care, I would like to (check all that apply):
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  • 76
    When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.
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  • 77
    I do hereby authorize the doctor of Nexus Family Chiropractic to administer chiropractic care that is necessary for my particular case. This may include consultation, examination, adjustments or any other procedure which is advisable and necessary for my health care. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I also clearly understand that if I do not follow the doctors specific recommendations at Nexus Family Chiropractic that I will not receive the full benefit from the services, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. I understand that payment for care is out-of-pocket and paid before or directly after services are rendered. If I wish to obtain reimbursement from my health insurance company, Nexus Family Chiropractic will supply the proper documentation necessary to receive reimbursement for services. Nexus Family Chiropractic is not liable for any lack of reimbursement from my health insurance company. I have read, understand, and hereby request chiropractic care based on the terms of acceptance and the consent to care.
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  • 78
    The following authorizes Nexus Family Chiropractic to use and/or disclose protected health care information in accordance with the following specific authorizations: I give permission to Nexus Family Chiropractic to use my name, address, phone numbers, and clinical records to contact me with birthday cards, holiday related cards, health related-emails and information about treatment alternatives or other health related information, as well as my advertisements, newsletters, or patient of the week/month postings. I give permission to Nexus Family Chiropractic to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protective health care information during my treatment. Should I need to speak with a doctor in private, the doctor will provide a private room for these conversations. By signing the following you are giving Nexus Family Chiropractic permission to use and disclose your protected health information in accordance with the directives listed above. ACKNOWLEDGEMENT OF RECEIPT & NOTICE OF PRIVACY PRACTICES I understand and have been provided with a notice of information practices that provides me a more complete description of information uses and disclosures, I understand that I have the following rights and privileges: * The right to review the notice prior to signing this consent * The right to object to the use of my health care information for directory purpose * The right to request restrictions as to how my health care information may be used or disclosed in this office to carry out treatment, payment, or health care operations.
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