German Village Patient

Personal Information

First Name *

Last Name *

Street Address *

City *

State/Province *

Zip Code *

Email *

Gender *

Male
Female
Other

Date of Birth *

Insured's Social Security #

Employer *

Type of Work *

Who referred you to this office?

Cell Phone *

Work Phone

Marital Status *

Emergency Contact

Name *

Home/Cell Phone *

Relationship *

Insurance

We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately.

Insurance Company *

Policy #

Group #

Reason for Visit

Primary Complaint(s) *

Have you been adjusted by a chiropractor before?* *

Are you pregnant? *

Do you exercise regularly? *

Health Habbits

Do you smoke? *

Do you drink alcohol? *

Do you drink coffee? *

Health Conditions

Please check each of the diseases or conditions that you have had now or in the past.

Informed Consent for Chiropractic Care

The nature of chiropractic treatment: Abnormal postural habits or distortions are a result of trauma or stress that have misaligned the vertebrae in your spine. These misalignments are called Subluxations and will cause stress to the spinal cord and the delicate nerves that pass between the vertebrae. The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, traction and therapeutic activities may also be used.

Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke has been estimated at one in one million to one in twenty million and can be even further reduced by screening procedures.

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 induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

Minor Patient Only: Guardian (Printed) Name / Relationship

X-Ray Authorization

As your healthcare provider, we are legally responsible for your chiropractic records. We must maintain a record of your x-rays in our files. At your request, we will provide you with a copy of your x-rays in our files. The fee for copying your x-rays on a disc is $10.00. The fee must be paid in advance. Digital x-rays on CD will be available within 72 hours of prepayment during regular hours of business.

Please note x-rays are utilized in this office to help locate and analyze musculoskeletal conditions. These x-rays are not used to investigate for medical pathology, however; if any abnormalities are found, we will bring it to your attention and refer you to any specialist for further medical evaluation.

Female Patients only: Please read carefully and check the box, then sign below if you understand and have no further questions, otherwise see our front desk for further explanation.

By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with the exposure to x-rays. After careful consideration I, therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case. To the best of my knowledge, I am not pregnant.

By signing below, you are agreeing to the above terms and conditions.

Patient Policies

Open Adjusting Environment:

I give Inner Health Chiropractic permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information. Should I ask to speak with the doctor in private, the doctor will provide a room for those conversations. I understand that I may choose treatment in a private room rather than in the open adjusting area. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations or presenting report of findings. These procedures are completed in a private, confidential setting. Please turn your cell phone OFF or on VIBRATE.

PATIENTS WITHOUT INSURANCE/SELF PAY/TIME OF SERVICE (TOS)

We request that 100% of each visit be paid at the time the services are received. Please ask the front desk about discount packages. We accept VISA, MASTERCARD, DISCOVER and AMEX.

GROUP OR INDIVIDUAL INSURANCE

Your insurance is an agreement between you and your insurance company. When possible, we will verify your benefits; however, the benefits quoted to us are not a guarantee of payment. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services. As a courtesy to you, our office will complete any necessary insurance forms at no additional charge, and file them with your insurance company.

FLEX PLAN – HSA/HRA ACCOUNTS

Please inform us if you have a medical savings account, sometimes known as a flex plan. We will be happy to provide you with a statement of your charges for reimbursement.

PERSONAL INJURY/AUTOMOBILE ACCIDENTS

Please present your auto insurance card, your health insurance card, and tell us if you have retained an attorney. There are three options available to a PI patient:

Pay cash for your care and we will submit reports whenever necessary.
We will bill (accept assignment) for the Med Pay portion of your auto insurance.
We will accept a letter of protection or Doctors Lien from an attorney and await payment at the time of settlement.

WORKERS COMPENSATION

If you are injured on the job, your care should be paid for under your employer's workers compensation insurance. You will need to inform your employer of the accident. If a settlement has been made within 90 days, or if you suspend or terminate care, any fees and services are due immediately.

I have read and understand the payment policy of Inner Health Chiropractic. I understand that my insurance is an arrangement between myself and my insurance company. NOT between Inner Health Chiropractic and my insurance company. I request that Inner Health Chiropractic prepare the customary forms at no charge so that I may obtain insurance benefits.

If your account is sent to an outside agency for non-payment, a 35% fee will apply.

By signing below, you are agreeing to the above terms and conditions.

Signature *

Printed Name *

Website

German Village

Dublin

North

East

West

Pickerington