PATIENT REGISTRATION FORM

GENERAL INFORMATION (PLEASE PRINT NEATLY)

Patient’s Name: __________________________________________________________________________________________

Last Name First Name Middle I

Address:_______________________________________________________________________ Apt. _____________________

City: ___________________________ State: ______ Zip: ___________ Email:_______________________________________

Work# ( ) _______________________ Cell# ( )_____________________Home Ph# ( ) ____________________

Date of Birth: MM: _______ DD: _________ YYYY_________ Sex: 􀀳Female 􀀳Male

Social Security # : ________-_______-_________ Marital Status: 􀀳 Married 􀀳 Divorced 􀀳 Single 􀀳 Living

Partner

Employer: _________________________________________________ Occupation: ___________________________________

Employer’s Address: ____________________________________ City: ___________________ State: _______ Zip: __________

Emergency Contact: ______________________________ Relation:_____________________ Ph#( )___________________

Address: _____________________________________ City: ___________________ State: ____________ Zip: _____________

RESPONSIBLE PARTY INFORMATION

Name of Guarantor: ____________________________________________ Date of Birth: ____________________________

Address (if different than above): ____________________________________________________________________________

City: _______________________________________________________ State: ___________________ Zip: _______________

HOW WERE YOU REFFERED TO OUR OFFICE?

􀀳 Internet; Search engine or website

name:___________________________________________________________________

􀀳 Referred by (Name of family, friend, co-worker, other):

________________________________________________________

Referring Doctor’s Name (if any): _________________________________________ Phone #: ( ) ____________________

Address: ___________________________________________ City: ____________________ State: _____ Zip: ____________

Who is your General Medical Doctor (if any): ___________________________________ Phone #: ( ) _________________

Address: ___________________________________________ City: ____________________ State: _____ Zip: ____________

 TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be
working towards the same objective.
Chiropractic has only one goal. It is important that each patient understand both the objective and the method
that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral
subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental, and social well being, not merely the absence of infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes
alteration of nerve function and interference to the transmission of mental impulses resulting in a lessening of the
body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease. We only offer to diagnose either vertebral subluxations or neuro-
musculoskeletal conditions. However, if during the course of a chiropractic spinal examination, we encounter non-
chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings,
we will recommend that you seek the services of another health care provider.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment
prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of
the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

THERE WILL BE NO REFUNDS ON THE BASIS OF UNMET EXPECTATIONS!

REFUNDS WILL ONLY BE ISSUED FOR UNUSED PREPAID VISITS.

I, ___________________________ have read and fully understand the above statements.

(please print your name)

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

______________________________ _______________
(signature) (date)

Consent to evaluate and adjust a minor child

I, ______________________________ being the parent/legal guardian of ________________________ have fully

read and fully understand the above terms of acceptance and hereby grant permission for my child to receive
chiropractic care.

Pregnancy Release
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates
have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an
unborn child. Date of last menstrual period: ____________________

______________________________ _______________
(signature) (date)
 PATIENT INFORMED CONSENT FORM

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain
rights to privacy regarding my protected health information. I understand that this information can and will be used
to:

􀀳 Conduct, plan and direct my treatment and follow-up among the multiple healthcare
providers who may be involved in that treatment directly and indirectly.

􀀳 Obtain payment from third-party payers.

􀀳 Conduct normal healthcare operations such as quality assessments and provider of care
certifications.

I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and
disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to
signing this consent. I understand that this facility has the right to change its Notice of Privacy Practices from time
to time and that I may contact this facility at any time at the address above to obtain a current copy of the Notice
of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry
out treatment, payment or health care operations. I also understand you are not required to agree to my
requested restrictions but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action
relying on this consent.

□ Informed Consent for Physical Therapy treatment

The term “informed consent” means that the potential risk, benefits, and alternatives of physical therapy treatment
have been explained to you. The therapist provides a wide range of services and I understand that I will receive
information at the initial visit concerning treatment options available for my condition.
Potential risk: I may experience an increase in my level of pain or discomfort, or an aggravation of my existing
injury or condition. This discomfort is usually temporary; if it does not subside in 24 hours, I agree to contact my
physical therapist.
Potential benefits: I may experience an improvement in my symptoms and increase in my ability to perform
daily activities.
I may experience decrease in pain and discomfort. I should gain a greater knowledge about managing my
condition and the resources available to me.
Alternatives: If I do not wish to participate in the therapy program, I will discuss my medical, surgical or
pharmacological alternatives with my primary care provider.

I have read the above information and consent to physical therapy evaluation and treatment.

Patients Name:_________________________________________________________________
Please print

Signature: _____________________________________________________________________

Relationship to Patient: ______________________________ ____________________

Date

____________________________________ _______________________________
Witness (for office use only) Date (for office use only)