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28 Chiropractic
New Patient Information Worksheet

Name:_______________________________ SS#:______________________ Age:_____ Birth Date:_________________

Address:_____________________________________ City:______________ State:______ Zip:_____________________

Home Ph: (_____ )_________________ Cell Ph: (_____) ___________________ Work Ph: (_____ )________________

Employer:______________________________________________ Email:______________________________________

Spouse Name:_________________________________ Spouses Birth Date:____________________________________

Referred By: Friend/Relative Physician Internet Yellow Pages Sign Other:____________________

Which one of our patients should we thank for referring you?_______________________________________________

Please list ALL surgeries:______________________________________________________________________________


List any medical conditions you are aware of:_____________________________________________________________


Who is your Primary Care Physician?___________________________ Ph Number:_______________________________

Is it OK to send updated reports and records to your Primary Care Physicians office? No Yes:_________________
(Please Initial)

*Females: Are you pregnant at this time? No Yes Due Date:__________________________

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 doctors 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-rays will be released from this office if I owe any money on my

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. Walthers office policies and consent to be treated by signing below:

Signature:_______________________________________________________________ Date:_____________________

Parent/Guardian Signature:__________________________________________________Date: ____________________

Route 28 Chiropractic 1240 State Route 28 Suite B Milford, OH 45150

Consent for Use or Disclosure of Health Information

Our Privacy Pledge

We are very concerned with protecting your privacy. 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.

Printed Name


Printed Parent/Guardian Name (if under 18 years old)

____________________________________ __________________________________
Patient Signature Parent/Guardian Signature (if under 18 years old)

____________________________________ __________________________________
Date Date

Route 28 Chiropractic 1240 State Route 28 Suite B Milford, OH 45150

Financial Agreement/Missed Appointments

Financial Responsibility

Payments for services are due at the time of services 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 will 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.

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 accurate information from the
insurance companies. Any unpaid balances no paid by the insurance are the patients responsibility.

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

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 plan 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 be billed to your insurance company, and must be paid before any other care is provided.

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

Printed Name


Printed Parent/Guardian Name (if under 18 years old)

____________________________________ __________________________________
Patient Signature Parent/Guardian Signature (if under 18 years old)

____________________________________ __________________________________
Date Date

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 provide us
with your email address. We promise never to sell or misuse your email information.

Email Address:__________________________________________________

Route 28 Chiropractic 1240 State Route 28 Suite B Milford, OH 45150


Patients Name: _______________________________________________________________ Date: ________________

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 !!!! ////

Route 28 Chiropractic 1240 State Route 28 Suite B Milford, OH 45150