Please check all that apply with regard to your reasons for consulting our office:
We thank you for your patience and cooperation in completely filling out this form.
PATIENT CONSENT TO XRAY
IName*authorize the performance of diagnostic x-ray examination on myself which Dr. Zwirn or the appropriate staff consider necessary or advisable in the course of examination and treatment.
VERIFICATION OF NON-PREGNANCY
This is to certify that to the best of my knowledge, I,Name am not pregnant and that Dr. Zwirn or the appropriate staff has my permission to perform diagnostic X- ray examination. I have been advised that x-rays can be hazardous to an unborn child. Date of last menstrual period: Date
CONSENT TO XRAY A MINOR
I, Parent Name authorize the performance of diagnostic x-ray examination, of my child or ward which Dr. Zwirn or the appropriate staff consider necessary or advisable in is a the course of examination and treatment. The patient, Minor Name is a minor, is a minor, Age years of age.
INFORMED CONSENT TO CHIROPRACTIC TREATMENT
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy, and if necessary, diagnostic x-rays on me (or the patient named below, for whom I am legally responsible: (Name* ) by the chiropractic physician and/or anyone working in this ( office authorized by the chiropractic physician. I have had an opportunity to discuss with the doctor named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic carries some risks to treatment; including, but not limited: fractures, disc injuries, strokes (CVA), dislocations, and sprains. I do not expect the physician to be able to anticipate and explain all risks and complications. Further, I wish to rely on the physician to exercise judgment during the course of the procedure which the physician feels are in my best interests at the time, based upon the facts then known. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by my physician. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at this facility.
Self Pay I will be paying cash at time of service, we accept cash, checks and cards. (All card transactions will have a 3% card fee added.)Health InsuranceI have health insurance. I will pay my initial deductible in full, if not already met. After my deductible is met I will pay my co-payment and/or percentage. I understand that I am ultimately responsible for my bill if my insurance carrier does not pay including, but not limited to, PiezoWave and DRX 9000 treatments, which are not covered by any insurance carriers at this time. Workers Comp I have been injured at work and have reported my injury to my employer. I have also complied with the necessary requirement set forth by the employer in order to obtain proper authorization for treatment. My claim number isClaim Numberand the insurance company handling my case is Insurance Company. Auto Accident I have been involved in an auto accident; an accident report has been filed with a police officer. I have contacted my insurance carrier and obtained a claim number. My claim number is Claim Number and my insurance company is Insurance Company.Auto Accident - No Insurance I have been involved in an auto accident but do not carry my own auto insurance. The attorney handling my case is Attorney. Slip & Fall* I have been involved in a slip and fall accident. The attorney handling my case is Attorney.