Online Patient Form

Name *

First

Last

Date of Birth *

Please use mm/dd/yyyy format

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Mobile Phone

Email *

Are you married?

Yes
No

Spouse's Name

Spouse's DOB

Please use mm/dd/yyyy format

Insurance Company Name

Policy Number

Phone Number (from back of card)

Employer

Occupation

Appointment

I currently have a scheduled appointment
I do not have a scheduled appointment at this time

Please list present complaints, injuries and duration

Have you had chiropractic care before?

Yes
No

Do you have health insurance?

Yes
No

Are you on Medicare?

Yes
No

Are you here for:

an auto accident
an on the job accident

Date of Injury

Do you have an attorney?

Yes
No

Name of primary care physician

Date of last visit

Date of last physical exam

Reason for physical exam

For women: is it possible you are pregnant?

Yes
No

Please list all accidents, falls, injuries, surgeries, major illnesses with dates

Are you presently taking any medications? (name, dosage, reason)

Below is a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.

Have you tested positive for HIV?

Yes
No

Check any of the following you have had in the past 6 months

Genito-urinary Code

Bladder Trouble
Discolored Urine
Painful/Excessive Urination

If you checked other problems, please list them

Females Only

When was your last period?

Are you pregnant?

Yes
No
Not Sure

Oswestry Questionnaire

Click one that applies to your specific case for each section

Pain Intensity *

I can tolerate the pain I have without having to use pain killers
The pain is bad but I manage without taking pain killers
Pain killers give complete relief from pain
Pain killers give moderate relief from pain
Pain killers give very little relief from pain
Pain killers have no effect on the pain and I do not use

Personal Care *

I can look after myself normally without causing extra pain
I can look after myself normally but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but can manage most of my personal care
I need help every day in most aspects of self care
I do not get dressed, it is too difficult and I stay in bed

Lifting *

I can lift heavy weights without extra pain
I can lift heavy weights but it gives me extra pain
Pain prevents me from lifting heavy objects off the floor, but I can manage if they are conveniently positioned
Pain prevents me from lifting heavy weights, but I can manage to lift medium weights if conveniently positioned
I can lift only very light weight
I cannot lift or carry anything at all

Walking *

Pain does not prevent me from walking any distance
Pain prevents me from walking more than 1 mile
Pain prevents me from walking more than ½ mile
Pain prevents me from walking more than ¼ mile
I can only walk using a stick or crutches
I am in bed most of the time and have to crawl to the toilet

Sitting *

I can sit in my chair as long as I like
I can only sit in my favorite chair as long as I like
Pain prevents me sitting more than 1 hour
Pain prevents me sitting more than ½ hour
Pain prevents me sitting more than 10 minutes
Pain prevents me from sitting at all

Standing *

I can stand as long as I want without extra pain
I can stand as long as I want but it gives me extra pain
Pain prevents me from standing for more than 1 hour
Pain prevents me from standing for more than ½ hour
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all

Sleeping *

Pain does not prevent me from sleeping well
I can sleep well only by using tablets
Even when I take tablets I have less than 6 hours sleep
Even when I take tablets I have less than 4 hours sleep
Even when I take tablets I have less than 2 hours sleep
Pain prevents me from sleeping at all

Social Life *

My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more energetic interests (e.g dancing etc)
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of pain

Traveling *

I can travel anywhere without extra pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys over 2 hours
Pain restricts me to journey of less than 1 hour
Pain restricts me to short necessary journeys under 30 minutes
Pain restricts me from traveling except to the doctor or hospital

Work *

I can do as much as I want
I can only do my usual work but no more
I can only do most of my usual work but no more
I cannot do my usual work
I can hardly do any work at all
I cannot do any work at all

Why Chiropractic?

People go to Chiropractors for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weigh your needs and desires when recommending your treatment program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Type of care desired *

Relief Care. Relief Care is the care necessary to eliminate your symptoms of pain, but not the cause of it. It is the same as drying a floor that was getting wet from a leak, but not fixing the leak.
Corrective Care. The goal of corrective care aims to not only eliminate the symptoms of pain, but also to correct the cause of the problem. Depending upon the condition or injury, corrective care varies in the length of time to stabilize the problem.
Check here if you want the doctor to select the type of care appropriate for your condition. Our office policy states that payment is due when services are rendered. As a courtesy to you, we will file your insurance claims for you.

Financial Policy

To expedite the scheduling of your next appointment and to help facilitate your payment process we accept the following methods of payment.

Payment Method *

Cash
Check
Credit Card (American Express, VISA, MasterCard) To provide you with the best possible timely service at our front desk, you may register your credit card in our vault. By doing so you have created a secure transaction. We will provide you with either an instant e-mail receipt or a paper receipt upon request.
Group Insurance: As a service to you, we will file your medical insurance for you. Your deductible will be met first, then you will pay your co-payment. Your co-payment is due at the time services are rendered. Certain charges that the insurance doesn’t pay for remain your responsibility.
Automobile Insurance: Before we can file your personal injury protection we must have verification of automobile insurance (“Med PAY”) and a copy of the accident report.
Workers Compensation: before you can be treated as a Workers Comp case, we must have written authorization from your employer, verifying that the injury sustained was work related and a case has been opened with a case number.
Liability (Attorney): This option is used only in the event that a Personal Injury case is filed without any other bases of payment prior to a settlement agreement being reached.

I have read the above and checked one method of payment

Name *

First

Last

Date *

Financial Policy

It is our firm belief that all of our patients deserve quality care. In order for us to provide this level of service, it is important that our patients understand our financial policies.

If we are participating providers in your plan, we will accept assignment for payment and submit a claim on your behalf to the insurance company. You must provide our office with accurate insurance information in order for us to file your claim. Failure to provide accurate information may forfeit your right for us to file your claim. Some insurance companies require you to satisfy an office copay and/or deductible before they submit payment. We require copays and/or deductibles be paid at the time services are rendered. It is important to remember that your insurance coverage is a contract between you and your insurance company. You are responsible for any balances or charges not covered by your insurance.

If you receive a patient statement, please remember you have already received services from our office and the balance is your responsibility. If you are unable to pay your balance in full, please contact our billing department to make payment arrangements.

Assignment and Instruction for Direct Payment to Doctor

| hereby direct and instruct my insurance company to pay Discover Specific Chiropractic. A photocopy of this assignment shall be considered as effective and valid as the original. | understand | am financially responsible for any amount not covered by my insurance policy. | also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case. This form is my signature on file.

Medicare Patients Only

Medicare will only pay for service that it determines to be “reasonable and necessary” under Section 1962(a) (1) of the Medicare law. If Medicare determined that a particular service, although it would otherwise be covered, is “not medically necessary” under Medicare program standards, Medicare will deny payment for that service. (X-rays and Examination) | have been notified by my physician that he/she believes that Medicare is likely to deny payment for my X-rays and Examination and | agree to be personally responsible for payment of the agreed services.

Privacy Policy

We are very concerned about protecting your privacy. We may disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health. We have more than one doctor in our office and your information may be shared with other doctors. You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. Any request, such as these, must be made in writing. However, we are not required to agree to your restrictions.

Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you with appointment reminders, information about treatment alternatives, or other health-related information that may be of interest to you. If this contact is made by phone and you do not answer, we will leave a voice mail. Our office sends out new patient letters, postcards, birthday cards, and statements periodically.

By signing this, I hereby acknowledge that I have read and understand Discover Specific Chiropractic’s privacy policy. I understand that I may obtain a copy of the privacy notice.

Privacy Policy *

I hereby acknowledge that I have read and understand Discover Specific Chiropractic’s privacy policy. I understand that I may obtain a copy of the privacy notice.

Name *

First

Last

Date *

Would you like to receive texts in regards to appointments/questions?

Yes
No

Online Patient Information Form

Below is a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.

Check any of the following you have had in the past 6 months

Females Only

Oswestry Questionnaire

Why Chiropractic?

Financial Policy

Financial Policy

Assignment and Instruction for Direct Payment to Doctor

Medicare Patients Only

Privacy Policy