Aloha! Welcome to Ohana Chiropractic and Wellness Center
Please fill out the New Patient paperwork below so we can get you scheduled for your visit with one of our amazing Doctors. This paperwork will be used for the offices of Dr. Joseph Kepo'o, Dr. Donald Whittaker, and Dr. Brian Massimini.
Today's Date
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Name
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First Name
Last Name
Address
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Street Address
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City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Date of Birth
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What name do you prefer to be called?
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Marital Status
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Married
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Number of Children?
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Please Select
0
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10+
Number of Children still at home?
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1
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10+
Please provide names and ages of your children if you have any.
Are you Employed
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Yes
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Profession and Employer
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How did you hear about our office?
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Friend/Family
Doctor/Other Office
Existing Patient
Ad
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Who may we thank for referring you?
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*If you don't know the name of the person who referred you, you can input NONE or UNKNOWN
Please Provide a list of Medical and Holistic Practitioners you are currently seeing.
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Have you been to a Chiropractor before?
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Yes
No
If Yes to the previous question, when was your last appointment?
How long did you receive care?
Have you ever been told you have any issues in your spine or nervous system?
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Yes
No
If Yes to the previous question, please share what you were told.
Please select all of the following that you've experienced
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Emotional Trauma or Abuse
Physical Trauma (ex. Car accident, work accident)
Head Trauma (Concussions: severe or multiple small. Also include experiences like heading in soccer where a head or fatigue was experienced after or during a game)
A Major Illness (ex. Lyme, Cytomegalovirus, Epstein Barr, Cancer, Stroke, Diabetes)
Local or General Anesthesia (ex. dental work, stitches, C-Section, Epidural, Surgeries)
Other
Briefly describe your health concerns that bring you into our office.
Our office and Dr's are not Medicare providers and we do not bill Medicare for any treatments in out office. Are you insured with Medicare?
Yes
No
Notice of Privacy Practices Acknowledgement Form
The offices of Dr. Joseph Kepo'o, Dr. Donald Whittaker, and Dr. Brian Massimini will never share your personal or private information with others. We may only disclose information about you in the following ways: 1)To another healthcare provider, hospital or facility if they request it in order to assist them in caring for you. 2)To an insurance carrier or employer if they are possibly responsible for payment or reimbursement. 3) If you are not available to receive an appointment reminder, a message may be left on your answering machine or with a person in your household or at work. We may also send you correspondence by email.
My signature acknowledges I have read this notice, understand it and agree with the policies explained.
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Printed Name
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First Name
Last Name
Date
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Clinic Policies
Please Initial each Policy Indicating Your Understanding of the Policy
Cancellation and Missed Appointments Policy: Scheduled appointment times are reserved for you. If an appointment is missed or canceled with less than 24 hours notice, you will be charged for the appointment rate. Exceptions can be made if you are sick or have an unavoidable emergency; in these cases, please contact the office as soon as possible to reschedule. If you are or will be more than 10 minutes late your appointment may need to be rescheduled.
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Insurance Notice: Our clinic does NOT bill insurance for any NAET, Emotion Code, EVOX, or ZYTO health scan treatments. Upon request, we can provide patients with a superbill which can be used to submit your own claim to your insurance company for Chiropractic, X-rays, Acupuncture, and Examinations. Note that everyone's insurance is different with what services they cover and how much. Many patients utilize their flex spending or Health Savings Accounts to get reimbursement.
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Payment Policy: All cash payments are required in full for the services provided each appointment.
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Medical Records: In accordance with HIPAA Privacy Laws, I understand that I have the right to see or obtain a copy of my medical records. I also understand that Ohana Chiropractic has the right to require up to 30 days in which to organize and prepare the information. (Please note that if you wish to obtain a summary or copy of all your records, there may be a $30 documentation fee.)
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Informed Consent for Treatment
Please read each of the sections below as we explain the potential risks of receiving care with each of the services we offer. Please note that the risks mentioned below are rare and that we take great care in making sure we avoid the likelihood of incident.
CHIROPRACTIC I understand that, as with any health procedure, there are certain conditions that may arise during a chiropractic adjustment. Those complications include but are not limited to: fractures, dislocations, muscle strain, costovertebral strains and separations. Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. This is a very rare occurrence. I understand the doctors screen patients for indications that they are candidates for chiropractic adjustments to the best of their ability. I do not expect the doctor to be able to anticipate all risk and complications during the course of the procedure(s) that the doctor feels at the time, based upon the facts then known, are in the best interest.
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ACUPUNCTURE and INTRAMUSCULAR and SUBCUTANEOUS INJECTIONS I understand that acupuncture is performed by the insertion of fine sterile needles through the skin and Injections will include ozone, homeopathic, and/or platelet plasma from your own blood at certain points (subcutaneous or intramuscular) on the body in an attempt to treat bodily dysfunction or disease, to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These may include, but are not limited to local bruising, minor bleeding, fainting, pain or discomfort, the possible aggravation of symptoms and, very rarely, organ puncture, nerve damage or infection.
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NAET,HRT,ASA BALANCE, AO ANALYZER, ZYTO I understand that NAET, HRT, ASA Balance, AO Digital Body Analyzer, Zyto are not medical diagnostic procedures and therefore does not diagnose a disease. NAET, HRT, ASA Balance, AO Digital Body Analyzer, Zyto uses various, standard diagnostic measures and modalities to diagnose the patient’s condition. NAET, HRT, ASA Balance, AO Digital Body Analyzer, Zyto gives the practitioner an indication as to the substance(s) in which the patient may have sensitivity to and to which areas of the body may be out of balance. The premise behind NAET, HRT, ASA Balance, AO Digital Body Analyzer, Zyto is to desensitize a patient to a substance(s) and balance the body overall through its own innate energy and abilities.
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NEUROPTIMAL is solely used as a tool for brain training and optimization and not as a means of diagnosis or as a medical intervention.
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I hereby request and consent to the performance of chiropractic adjustments, a comprehensive exam, diagnostic x-rays, physical therapy techniques, acupuncture, injection therapy, nutritional guidance and all other therapies as mentioned above on me (or on the patient named below for which I am legally responsible) by the licensed doctors of chiropractic at the offices of Dr. Joseph Kepo'o, Dr. Donald Whittaker, and Dr. Brian Massimini.
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Printed Name
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First Name
Last Name
Please Provide the Date of Signature
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Notice of Privacy Practices Acknowledgment Form: The offices of Dr. Joseph Kepo'o, Dr. Donald Whittaker, and Dr. Brian Massimini will never share your personal or private information with others. We may only disclose information about you in the following ways: 1) To another healthcare provider, hospital or facility if they request it in order to assist them in caring for you. 2) To insurance carrier or employer if they are possibly responsible for payment or reimbursement of services. 3) If you are not available to receive an appointment reminder, a message may be left on your answering machine or with a person in your household or at work. We may also send you a correspondence by email.
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Please input the date this was signed
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Please Print the name of the person signing above.
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