• New Patient Intake Form

    New Patient Intake Form

  • Patient Information

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  • How Did You Hear About Us?

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  • Insurance Information

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  • Primary Complaint:

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  • Secondary Complaint:

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  • Tertiary Complaint:

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  • Quaternary Complaint:

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  • Top 3 Health Goals:

  • History

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  • Social History & Habits:

  • Health Checklist

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  • Terms of Acceptance

     

    In order to provide for the most effective healing environment, most effective application of chiropractic procedures, and the strongest possible doctor-patient relationship, it is our wish to provide each patient with a set of parameters and declarations that will facilitate the goal of optimum health through chiropractic. To that end, we ask that you acknowledge the following point regarding chiropractic care and the services that are offered through this clinic:

    Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. Chiropractic is a separate and distinct science, art and practice. It is not the practice of medicine.
    Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functions through the adjustment of spinal subluxation(s). Subluxations are deviations from normal spinal structures and configurations that interfere with normal nerve processes.
    The chiropractic adjustment process, as defined in the law of this jurisdiction, involves the application of a specific directional thrust to a region or regions of the spine with the specific intent of re-positioning misaligned spinal segments. This is a safe, effective procedure applied over one million times each day doctors of chiropractic in the United States alone.
    A thorough chiropractic examination and evaluation is part of the standard chiropractic procedure. The goal of this process is to identify any spinal health problems and chiropractic needs. If during this process, any condition or question outside the scope of chiropractic is identified, you will receive a prompt referral to an appropriate provider or specialist, according to the initial indications of the need.
    Chiropractic does not seek to replace or compete with your medical, dental or other type(s) of health professionals. They retain responsibility for care and management of medical conditions. We do not offer advice regarding treatment prescribed by others.
    Your compliance with care plans, home and self-care, etc., is essential to maximum healing and optimal health though chiropractic
    We invite you to speak frankly to the doctor on any matter related to your care at this facility, its nature, duration, or cost, in what we work to maintain as a supporting, open environment.
     By my signature below, I have read and fully understand the above statements.

    All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my satisfaction. I therefore accept chiropractic care on this basis.

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  • HIPAA Compliant Authorization to Release Health Information


    To Practice Members:


    Federal law requires us to disclose our Privacy Practices to you. We trust that by taking a few moments to read our notice, you will have a better understanding of how we strive to protect the information you entrust to us.


    Types of information we collect in the day-to-day operations of our chiropractic office, health care and related information such as your name, address, date of birth, medical history, diagnosis, treatment, health plan or payer information and financial responsibility are collected. This ‘personal health information’ (PHI), is also known as ‘protected health information’.


    Confidentiality and security of your personal information: We restrict access to PHI to those who need the information to provide treatment, payment, or other health care operations to our patients. There are certain instances in which information may need to be disclosed even without prior permission from the patient. This would be for national priority purposes only: if required by law, public health activities, victims of abuse, neglect, or domestic violence, judicial and administrative proceedings, research, serious threats to health or safety, etc.


    A complete chiropractic analysis and examination must be completed and additional steps may be needed to make the proper diagnosis. After collecting and using this personal information, it may be necessary to disclose certain information to other health care professionals or third-party participants. Your information is private and confidential and there are policies and procedures in place to protect the information against unlawful use and disclosure. Access to your PHI is restricted to only those employed by Clear Connections Chiropractic who needs it to provide services or benefits to our patients and their dependents.


    If you wish to grant family or loved ones’ access to your health information, please indicate their information below.
    Written or verbal information will be provided upon request only to those listed below.

  • By signing below, you are acknowledging that you have read and understand the privacy policy and are agreeing to the release of your personal health information for the above-mentioned reasons

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  • INFORMED CONSENT FOR CHIROPRACTIC CARE

    CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.

     

    PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.

     

    I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT.

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