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Rt.$28$Chiropractic $ New$Patient$Information$Worksheet$

$ $ Name: $$$SS#: $Age: $Birth$Date: $ $ Address: $$City: $State: $Zip: $ $ Home$Ph:$$(
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Name:
$$$SS#:
$Age:
$Birth$Date:
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Address:
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Home$Ph:$$(
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$$$$Cell$Ph:$(
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$$Work$Ph:$(
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Employer:
$$Email:
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Spouse$Name:
$Spouse’s$Birth$Date:
$
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Referred$By: $ $ $$ $$ ⃝$ $ Friend/Relative$$$$ $ $ $ ⃝$ $ Physician $$$ $$$ ⃝$ $ Internet $$$ $$$ ⃝$ $ Yellow$Page s $$$ $$$ ⃝$ $ Sign $$$ $$$ ⃝$ $ Other:
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Which$one$of$our$patient’s$should$we$thank$for$referring$you?
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Please$list$ALL$surgeries:
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List$any$medical$con ditions$you$are$aware$of:
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Who$is$your$Primary$Care$Physici an?
$Ph$
Number:
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Is$it$OK$to$send$updated$reports$and$records$to$your$Primary$Care$Physician’s$office ? $$$ $ " ⃝" " No """" "" ⃝" " Yes:
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$$$$$$$$$$$$$$$ (Please"Initial) " "
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*Females:""Are"you"pregnant"at"this"time? """"" " ⃝" " No """"" "" ⃝" " Yes""""Due"Date:
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Office"Policies:$$ If#I#am#accepted#as#a#patient#at#Rt.#28#Chiropractic,#I#agree#to#pay#for#all#services,#including#services#not#
covered#by#my#insurance#company.##If#I#suspend#(or#terminate)#my#treatment#without#the#doctor’s#permission,#it#will#be#
understood#that#I#have#reached#maximum#healing#for#my#condition.##I#then#agree#to#be#fully#responsible#for#my#condition#
and#future#care.##I#understand#that#no#medical#records#or#x B rays#will#be#released#from#this#office#i f#I#owe#any#money#on#my#
account.# #
$
Consent"to"Treat : $$ I#also#understand#that#no#cures#are#promised#(or#implied)#and#any#risks#regarding#care#at#this#office#
will#be#explained#to#me#upon#my#request.##I#now#authorize#Dr.#Walther#to#proceed#with#any#necessary# treatment.##I#have#
read#Dr.#Walther’s#office#policies#and#consent#to#be#treated#by#signing#below:$
$
$
Signature:
"Date:
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Parent/Guardian"Signature:
Date:"
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Route$28$Chiropractic$$$$$$1240$State$Route$ 28$$$$Suite$B$$$Milford,$OH$4515 0 $

$ Consent"for"Use"or"Disclosure"of"Health"Information " "
$
Consent"for"Use"or"Disclosure"of"Health"Information "
"
Our"Privacy"Pledge "
We$are$very$concerned$with$protecting$your$pri vacy.$$While$the$law$requires$us$to$give$you$this$disclosure,$please$
understand$that$we$have,$and$always$will,$respect$the$privacy$of$your$health$information. $
$
However,$there$are$several$circumstances$in$which$we$may$have$to$use$to$disclose$your$health$care$information.$$$We$
will$disclose$your$health$information$and$billing$information$if: $
It$is$necessary$to$refer$you$to$another$provider$or$hospital$for$a$diagnosis,$assessment,$or$treatment$of$your$
health$condition. $
Another$party$is$responsible$for$the$payment$of$your$services. $
We$need$to$use$your$health$information$within$our$practice$for$quality$control$or$other$operation$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.$$We$reserve$the$right$to$change$
our$privacy$practices$as$described$in$that$notice.$$If$we$make$a$change$to$our$privacy$practices,$we$will$notify$you$in$
writing$when$you$come$in$for $treatment$or$by$mail.$$Please$call$us$at$any$time$for$a$copy$of$our$privacy$notices. $
$
Your"Right"To"Limit"Uses"or"Disclosures"
"
You$have$the$right$that$we$do$not$disclose$your$health$information$to$specific$individuals,$companies,$or$organizations.$$
If$you $would$like$to$place$any$restrictions$on$the$use$or$disclosure$of$your$health$information,$please$let$us$know$in$
writing.$$We$are$not$required$to$agree$to$your$restrictions.$$However,$if$we$agree$with$your$restrictions,$the$restriction$is$
binding$on$us. $
$
Your"Right"To"Revoke"your"Authorization"
You$may$revoke$your$consent$to$us$at$any$time;$however,$your$revocation$must$be$in$writing.$$We$will$not$be$
able$to$honor$your$revocation$request$if$we$have$already$released$your$health$information$before$we$receive$
your$request$to$revoke$your$authorization.$$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!have!read !your!consent!policy!and!agree!to!it!in!terms.!
I!am!also!acknowledging!that!I!have!received!a!copy!of!this!notice . $
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Printed$Name $
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$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
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Patient$Signature$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Parent/Guardian$Signature$(if$under$18$years$old) $
$$$$$$$$$$$$$$$$$$$$$$$$$$$
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Date$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Date$
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Route$28$Chiropractic$$$$$$$1240$State$Route$ 28$$$$Suite$B$$$Milford,$OH$4515 0 $
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Financial"Agreement/Missed"Appointments"

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Financial"Responsibility"

Payments$for$services$are$due$at$the$time$of$servic es$are$rendered$unless$other$arrangements$have$been$approved$in$ advance$by$our$staff.$$If$you$ have$ a$co _ pay,$we$will$accept$that$until$we$have$received$notice$or$payment$from$your$ insurance$company.$$We$wi ll$file$your$insurance$claims$as$a$courtesy.$$You$must$realize$that$your$insurance$is$an$ agreement$between$you$and$your$insurance$company.$$We$are$not$part$of$that$contract.$

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Our$fees$normally$fall$within$the$UCR,$which$is$defined$as$the$usual,$customary,$ and$reasonable$charges$for$this$region.$$ Not$all$insurance$companies$will$pay$for$services$performed$at$this$office.$$We$will$try$to$provide$you$with$an$accurate$ estimation$of$what$your$out _ of _ pocket$responsibility$may$be,$but$we$are$not$always$given$accur ate$information$from$the$ insurance$companies.$$Any$unpaid$balances$no$paid$by$the$insurance$are$the$patient’s$responsibility.$$ $

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By!signing!below,!I!understand!this!agreement!between!the!office!and!myself.!!I!am!ultimately!responsible!for!the! balance!of!my !account!for!any!professional!services!rendered.!

Missed"Appointments "

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It$is$the$goal$of$this$office$to$help$each$patient$achieve$his$or$her$ultimate$level$of$overall$health.$$In$order$for$this$to$occur,$it$is$ important$for$you$to$make$all$scheduled$appointments,$as$following$your$treatment$pl a n$is$ important $for$you$to$achieve$this$goal.$$$

$

In$order$for$our$office$to$assist$you$in$your$recovery$and$wellness,$we$have$set$aside$time$specifically$for$you$with$Dr.$Walther,$the$ therapists,$or$both.$$If$you$are$ unable$to$keep$a$scheduled$appointment,$it$is$important$for$you$to$make$an$appointment$for$later$ that$day.$$If$you$are$unable$to$make$your$appointment$that$day,$then$you$should$make$it$for$the$next$available$day.$$$

$

If$you$need$to$change$your$appointment,$please$kindly$give$us$a$24$hour$notice.$$Our$office$reserves$the$right$to$charge$for$missed$

appointments$without$prior$notification.$$The$office$charges$$50.00.$$This$fee$is$not$the$responsibility$of$your$insurance$company$(if$

you$have$insurance),$cannot$b e$billed$to$your$insurance$company,$and$must$be$paid$before$any$other$care$is$provided. $$ $

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By!signing!below,!I!fully!understand!this!agreement!between!the!office!and!myself.!!

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$$ $ $ $ Printed$Name $ $
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Printed$Name $
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$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Printed$Parent/Guardian$Name$(if$under$18$years$old) $
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Patient$Signature$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Parent/Guardian$Signature$(if$under$18$years$old)$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
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Date$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $ $$$$$ Date $

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We$pride$ourselves$in$using$every$avenue$to$educate$and/or$contact$our$patients.$$Occasionally,$our$office$sends$ updates$and$important$information$through$email.$$So$that$you$receive$this$important$information,$please$pro vide$us$ with$your$email$address.$$We$promise$never$to$sell$or$misuse$your$email$information. $

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Email $ A d dress :

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Route$28$Chiropractic$$$$$$$1240$State$Route$ 28$$$$Suite$B$$$Milford,$OH$4515 0 $

SYMPTOM"DIAGRAM$

Patient’s$Name:$ $Date:$ $
Patient’s$Name:$
$Date:$
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Use$the$following$drawing$to$indicate$the$location$of$your$symptoms$at $the $

present$time.$Use$the$various$symbols$to$describe$the$symptoms. $

Aches$$ $$$Numbness$$$$$$Pins/Needles$$$$$$Burning$$$$$$Stabbing$

XXXX$$$$$$$$$$$++++$$$$$$$$$$$$$$$$$$$0000$$$$$$$$$$$$$$$$$!!!!$$$$$$$$$$$$$$$////$

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$ $ $ $ Route$28$Chiropractic$$$$$$$1240$State$Route$ 28$$$$Suite$B$$$Milford,$OH$4515 0 $ $
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Route$28$Chiropractic$$$$$$$1240$State$Route$ 28$$$$Suite$B$$$Milford,$OH$4515 0 $
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