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New Patient Form
PATIENT INFO:
Name:

First Name Middle Name Last Name
DOB:

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Address:

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example@example.com
EMERGENCY CONTACT:
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PRIMARY INSURANCE:
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OTHER INFO:
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Referred By:
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Type of injury:

PersonalAuto
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Appt. Time:

Kaliko Chiropractic
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic and / or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as backup for the doctor of chiropractic named above, including those working at the clinic or office listed above or any other office or clinic.

I have had the opportunity to discuss with the doctor of chiropractic and / or with other office or clinic personnel the nature and of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to fractures, dislocations, strokes and sprains. I do not need or expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the then known, is in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I intended this consent form to cover the entire course of treatment for my pæsent condition and for any condition(s) for which I may seek treatment.
Print Patient's Name or Name of Patient Representative
Relationship
Date

MonthDay Year
Date
Signature Patient's Name or Name of Patient Representative

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Relationship
Date

MonthDay Year
Date
CONSENT TO TREATMENT OF MINOR
I (we) being the parent(s) of Type a label , a minor, the age of Type a label years, do hereby consent, authorize and request Kaliko Chiropractic, Dr. Micheal Kaliko, and whomever he may designate as his assistant to administer treatment as he/she so deems necessary on the above minor. I agree to hold him free and harmless from my claims, suits of damages or complications, which may result from treatment.
Signature of Parent of Guardian

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Signature of Witness

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Date

MonthDay Year
Date
SIGNATURE ON FILE

I authorize use of this information on all my insurance submissions.
I authorize release of information to all my insurance companies.
I understand that I am responsible for all my bills.
I authorize my doctor to act as my agent in helping me to obtain payment from my insurance company.
I authorize payment direct to my doctor.
I permit a copy of this authorization to be used in place of the original.
I authorize that I am responsible for payment of an office visit on all missed appointments lacking a 24 — hour cancel notice.
Print Name
Signature

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Date

MonthDay Year
Date
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me will be immediately due and payable. I also understand that if I suspend or terminate my care and treatment any fees for professional services rendered me will be immediately due and payable. I, the undersigned, affirm and declare that I have been advised by the Doctor's office that the bringing of a fraudulent claim is a crime punishable by imprisonment and / or fine, and that the Doctor's office will not treat and / or be part of such fraudulent claims. I hereby authorize the Doctor to examine and treat any condition as he / she deems appropriate through the use of Chiropractic Health Care. I give authority for all of these procedures to be performed. It is understood and agreed the amount paid the Doctor for X-ray negatives will remain the property of this office. I also agree that I am responsible for all bills incurred at this office.
Signature of Patients, Parent or Guardian authorizing care

Clear
Date

MonthDay Year
Date

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Kaliko Chiropractic required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information
Treatment
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.
Payment
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
Workers' Compensation
We may disclose your health information as necessary to comply with State Workers' Compensation Laws.
Emergencies
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement.
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Deceased Persons.
We may disclose your health information to coroners or medical examiners.
Organ Donation.
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
Reasearch.
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
Public Safety.
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government Agencies.
We may disclose your health information for military, national security, prisoner and government benefits purposes.
Marketing
We may contact you for marketing purposes or fundraising purposes.
Change Ownership.
In the event that Kaliko Chiropractic is sold or merged with another organization, your health information/ record will become the property of the new owner.

Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, Kaliko Chiropractic that is not required to agree to the restriction that you requested.
- You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
- You have the right to inspect and copy your health information.
- You have a right to request that Kaliko Chiropractic amend your protected health information. Please be advised, however, that Kaliko Chiropractic is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.
- You have a right to receive an accounting of disclosures of your protected health information made by Kaliko Chiropractic.
- You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes this Notice Of Privacy Practices
Kaliko Chiropractic reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Kaliko Chiropractic is required by law to comply with this Notice.
Kaliko Chiropractic is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Judy Strohfrldt by calling this office at (310) 855-9899. If Ms. Strohfeldt is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
Complaints
Complaints about your Privacy rights, Or how Kaliko Chiropractic has handled your health information should be directed to Judy Strohfeldt by calling this office at (310) 855-9899 If Ms. Strohfeldt is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
This notice is effective as of Date I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Kaliko Chiropractic with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.
Patient's Name
Patient's Signature

Clear
Date

MonthDay Year
Date
Should be Empty:

	Left	Right	Below
Headaches
Jaw
Eye
Neck
Upper Back
Mid Back
Low Back
Chest
Abdomen
Ribs
Buttocks
Shoulder
Forearm
Hand
Hip
Leg
Foot

	Left	Right	Both
Head
Shoulder
Arm
Hand
Hip
Leg
Foot

	Brings On	Aggravates	Relieves
In the A.M.
In the P.M.
Bending forward
Bending back
Bending left
Bending right
Twisting Left
Twisting Right
Coughing
Straining
Standing
Sitting
Lifting

New Patient Form

PATIENT INFO:

EMERGENCY CONTACT:

PRIMARY INSURANCE:

OTHER INFO:

Kaliko Chiropractic

CURRENT HEALTH CONDITION

PAST HEALTH HISTORY

Activities of Daily Living Assessment

NOTICE OF PRIVACY PRACTICES