• New Patient Form

    This form is HIPAA- compliant.
  • Information regarding who is filling out the form.

  • Patient Information

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  • Emergency Contact Info

  • Patient History

  • Social History

  • Patient Complaint

    *If you have two areas of pain (i.e. neck and back), please use the secondary complaint section found below*
  • *If you have any further complaints, please let the doctor know*

  • Family History

  • Acknowledgement of Receipt of Notice of Privacy Practices

  • Oswestry Disability Index

  • Patient Certification

  • I certify that the above information is true and correct and I hereby authorize the release of any information required to secure payment for services rendered.  I also authorize and direct that any insurance or medical coverage benefit payments to which I may be entitled shall be paid directly to Family Chiropractic Center. 

    I understand and agree that I am financially responsible for and will promptly pay any non-covered services including, but not limited to, deductible and co-pay. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care.

    We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information please ask for the HIPPA notice before signing this. If there is anyone who you do not want to receive your medical records, please inform our front desk.

  • I have received a copy of this office's Notice of Privacy Practices. I authorize Family Chiropractic Center to disclose any protected health information to the individual(s) listed below. 

  • Informed Consent

  • I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures including examination tests, diagnostic x-ray(s) and physical therapy techniques, on me (or the patient named below for which I am legally responsible) which are recommended by the doctor of chiropractic named below or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working for or associated with, or serving as back-up for the doctor of chiropractic named below. 

    I understand that, as with any health care procedure, there are certain complications which may arise during a chiropractic adjustment. Those complications include, but are not limited to: fractures, disc injuries, dislocations, muscle strain, Horner’s syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications, including stroke. I do not expect the doctor to be able to anticipate all of the possible risks and complications. I wish to rely on the doctor to exercise judgement during the course of the procedure(s) which the doctor feels and the time, based upon the facts then known, are in my best interest. 

    I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed. 

    I have read the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing recommended treatment. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

    Name and Address of Office or Clinic:                               Name of Doctor(s):

    Family Chiropractic Center of Pittsburgh                            Dr. Kevin S. Hartung

    5168 Campbells Run Rd.                                                   Dr. Jason E. Bean

    Pittsburgh, Pa 15205

     

    DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE INFORMATION

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