EWC_ReActivation

Re-Activation Updated Health Record

East West Chiropractic
Today's Date*

MonthDayYear
Date
Name:*

First NameLast Name
Guardian's Name (if minor)
Address*

Address

Street Address Line 2

CityState

Zip
Birth Date*

MonthDayYear
Date
Age*
Ethnicity
Gender*

MaleFemale
Cell Phone*
Home Phone
Work Phone
Please enter a valid phone number.
E mail*
example@example.com
Occupation*
Employer
Primary Care Physician*
Primary Care Physician City*
Marital Status*

MarriedSingleWidowedDivorced
Emergency Contact*
Relationship to You*
Emergency Contact Phone #*
Are you insured?*

YesNo
Insurance Company
Insurance ID#
Insurance Group #
Cardholder's Name
Cardholder's Date of Birth

MonthDayYear
Date
Your Social Security #

For Women Only:
Start Date of Last Menstrual Cycle:
Are you taking birth control? (yes or no)
Are you pregnant? (yes or no)
If yes, when are you due?

Our Privacy Policy

While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health information.
- We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health conditions.
- We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services
- We may need to use your health information within our practice for operation purposes.
We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form. (164.520)
Your Right to Limit Uses or Disclosures: You have the right to request that we do not disclose your health information to certain individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions.
Your Right to Revoke Your Authorization: You may revoke your consent to us at any time; however, your revocation must be in writing and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

I authorize you to use and disclose my information in the manner described above, to my primary care physician, and to:
Name: blanks*
Relationship to patient: blank*

I have read your consent policy and agree to its terms.
Initials: Signature*
Informed Consent to Chiropractic Treatment

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device to adjust/manipulate your joints. You may hear a “pop” or “click” like when a knuckle is “cracked”, and you may feel movement in the joint. Various ancillary procedures, such as hot or cold packs, electric stimulation, therapeutic ultrasound, and traction as well as exercise instruction and other modalities may also be used. There are inherent risks in all treatment derived by any health care provider ranging from taking a single aspirin to a complicated brain surgery. Chiropractic care is no exception. Although we take every precaution, there is a very low incidence of complication associated with chiropractic services, and anyone undergoing adjustment or manipulative therapy procedures should know the possible hazards and complications which may be encountered. These include, but are not limited to fractures, disc injuries, stroke, dislocations, sprains, and those which related to physical aberrations unknown or reasonably undetectable by the doctor.

I understand that the practice of neither chiropractic nor medicine is an exact science and that my care may involve the making of judgments based upon the facts known to the doctor at the time; that it is not reasonable to expect the doctor to be able to anticipate or explain all risks and complications; that an undesirable result does not necessarily indicated an error in judgement; that no guarantee as to results has been made to nor relied upon by me, and I wish to rely on the doctor to exercise judgement during the course of the procedure which he/she feels at the time, based upon the facts then known, is in my best interests.

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and include chronic pain cycles. It is quite probably the delay of treatment will complicate the condition, make further rehabilitation more difficult or impossible. Concerns or questions: please ask your doctor to explain any concerns about treatment you may have.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures on me or on my dependent/charge, by the licensed Doctor of Chiropractic (D.C.) employed or engaged in practice at East West Chiropractic.

I have read the above consent to chiropractic care. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment.
Initials: Signature*
Emails and Appointment Reminders

We may need to use your name, address, phone number and your clinical records to contact you with appointment reminders (text and email), information about treatment alternatives, or other health related information that may be of interest to you. This information may also be used for the purpose of sending birthday/holiday cards and messages, occasional newsletters, etc. If this contact is made by phone and you do not answer, a message will be left on your answering machine. By signing this, you are giving us authorization to contact you with these reminders and information. Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone who as access to the reminder or other information and may no longer be protected by the federal privacy rules. You have the right to refuse this authorization. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care. You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, and other health related information or marketing at any time. Telephone calls, text messages, and emails may be monitored for quality control.

I authorize you to use and disclose my health information in the manner described above.
Initials: Signature
Our Payment Policy

I understand that all services are to be paid in full at the time of service. I hereby authorize the doctor to release all information necessary to secure the payment benefits. I clearly understand that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional service rendered to me will be immediately due and payable. I authorize the use of signature on my insurance submissions.
Name: First Name   Last Name
Signature:   Signature
Date:   Date
Should be Empty:

Re-Activation Updated Health Record

Reason for This Visit

Health History

For Women Only: