New Patient

"*" indicates required fields

Legal Name*

First Last

Nickname or name you preferred to be called

DOB*

Age*

SSN*

Gender*

Preferred Pronouns (optional)

Marital Status*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Work Phone

Email*

Employer

Occupation

Spouse (if applicable)

Spouse's Employer

Emergency Contact

Relationship

Emergency Contact Phone

Who referred you to, or how did you hear about, our office?*

Do you have insurance?*

Yes

If yes, please provide front desk with copy of insurance card(s)

Insurance Company

Insurance ID Number (include alpha prefix if applicable)

Insurance Group Number

Is your visit due to a motor vehicle accident?*

Yes

Your present complaints/symptoms

List other doctor(s) seen for this condition

Personal Medical History

(if any of the any of the following are relevant to your medical history, please select all that apply)

Have you ever had chiropractic care?

Yes

Date of last adjustment

Have you ever had massage therapy?

Yes

Date of last massage

Describe any operations you've had and dates

Have you been treated by a physician for any health conditions in the last year?

Yes

Describe condition

Date of last physical exam

Are you now taking any medications?

Yes

What kind?

What supplements/vitamins are you currently taking?

Are you pregnant?

Yes

Date of last menstrual period

Patient's signature*

Date*

Printed name if signed on behalf of patient

Relationship

Office Policy

The following is an explanation of our office policies. We believe that a clear understanding will allow us both to concentrate on the most important issues; regaining and maintaining your health. We will be happy to answer any questions you may have regarding our policies, your account or insurance coverage

Complimentary Consultation: Natural Way Chiropractic will conduct a special “no charge” consultation, or brief conference, with anyone interested in finding out if chiropractic can help them with their individual health problem. There is no charge or obligation in connection with this appointment.

Patient Payment Policy: We feel the patient’s health needs are paramount. Therefore, the following Patient Care Services policy is an attempt to allow you, the patient, to receive the care you need and clear your balance with the least amount of difficulty.

Patient Care Services: Payment in full for all services is due at the time of service unless other arrangements have been made. Payment arrangements may be made with the office and payments must be made no less than monthly. Please understand that all services rendered to you are charged directly to you and you are responsible for payment, regardless of your insurance coverage. Properly documented Worker’s Compensation and auto accident claims are not required to pay at the time of service if appropriate forms and liens are signed.

Our Policy on Health Insurance: Many insurance policies cover chiropractic care. We will be happy to file your insurance claim for you and do everything we can to ensure you receive reimbursement. However, we cannot take responsibility for what your health insurance will or will not cover. It is important that you understand that health and accident insurance policies are an arrangement between an insurance carrier and you, the patient, their insured. Of course, Natural Way Chiropractic will prepare any necessary reports and forms to assist you in collecting from your insurance company. Furthermore, any amount authorized to be paid directly to Natural Way Chiropractic will be credited to your account upon receipt.

Appointments: Our office sends email and text appointment reminders, however, they are a courtesy only and not to be relied on. Please call our office as soon as possible if you are not going to make your scheduled appointment. To better serve our patients, we ask that you call if you are unable to make your appointment or if you are running late. Your appointment time is reserved for you. If you fail to notify our office, it leaves a time slot open that could be used to help someone else. For massage therapy services, our office has no show/late cancellation fees if we fail to receive 24 hours notice prior to your appointment as well as late arrival/early departure fees. Fees are dependent on the service and length of time you were scheduled.

Identification Policy: Natural Way Chiropractic requires a copy of photo identification (ex: driver’s license, passport, student ID) to be on file in order to receive care. Also, we require an electronic photo be taken and placed into your medical chart for verification purposes.

Questions and Answers: Your questions about any aspect of your care or account are invited. Please feel free to ask the Doctor or any available staff member. We will make every effort to answer and address your concerns.

Patient's signature*

Date*

Printed name if signed on behalf of patient

Relationship

Privacy Practices and Releases

Our doctors take your heathcare seriously and find it extremely important to keep your primary care provider up to date on your care in our offices. Please provide us with the name andlocation of your PCP and we will send them your current exam findings and any other requested information.

Primary Care Provider*

Location/Office*

Additional Disclosure Authority

In addition to the allowable disclosures described in "Notice of Privacy Practices", I hereby specifically authorize disclosure of my protected health care information to the person indicated below.

Name*

Relationship*

Name

Relationship

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting Natural Way Chiropractic.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

Patient's signature*

Date*

Printed name if signed on behalf of patient

Relationship

Informed Consent

To Our Patients:

Chiropractic examination and therapeutic procedures (including spinal adjustment, cold application, and manual muscle therapy) are considered safe and effective methods of care. Any procedure intended to help may have complications. While the chances of experiencing complications are very small, it is the practice of this clinic to inform our patients about them. Side effects include, but are not limited to soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More serious complications are extremely rare and their association with spinal adjustments (manipulation) is debated. These complications include injury to the arteries in the neck which may be associated with stroke and serious neurologic impairment, injuries to the spinal discs and spinal fractures.

Therapeutic procedures (including massage therapy, cold application, and heat application) are considered safe and effective methods of care. Draping will always be utilized, and only the body part being worked on will be exposed if necessary. Any procedure intended to help may have complications. While the chances of experiencing complications are very small, it is the practice of this clinic to inform our patients about them. Side effects include, but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms.

I understand it is my responsibility to let my massage therapist know of any pain or discomfort I am having during the session, or if I’d like the pressure to be less or more at any time. I have also notified my massage therapist of all known medical conditions and injuries. I also understand this is a doctor’s office and that my massage is entirely therapeutic and non-sexual in nature.

Patient's Signature*

Date*

Print Patient's Name*

DOB*

Printed name if signed on behalf of patient

Relationship

Notice of Likelihood of Insurance Denial of Benefits

I understand that my insurance company may deny payment for the service provided to you for the following reasons:

That the particular services is not reasonable and necessary under my insurance companies standards.

For this reason, please read and sign the following statement:

"I have been informed by my physician that they believe that, in my particular case, my insurance may deny payment for the service identified above, for the reason stated. If my insurance denies payment I agree to be personally responsible for payment of said services."

Patient's Signature*

Date*

Printed name if signed on behalf of patient

Relationship

Assumption of Financial Responsibility

Explanation of benefits disclaimer

I, the undersigned patient, completely understand that Natural Way Chiropractic provides insurance billing and insurance benefit verification as a courtesy to the patients. I understand that the service Natural Way Chiropractic provides for verification of insurance coverage is in no way a promise of payment by my insurance company. If my insurance company denies my claim(s) for any reason, or misquotes my benefits to Natural Way Chiropractic, the balance of my account will be billed to me and due to the clinic.

It is the policy of Natural Way Chiropractic to never enter into a dispute with your insurance company for any reason.

I, the undersigned patient, completely understand the insurance services provided to me regarding my insurance coverage as stated above. I understand that my signature below serves as a "signature on file" to bill the above insurance company and allows this clinic to accept assignment of insurance benefits. I understand the above "Benefits Disclaimer" and my financial responsibilities to any services rendered by this clinic.

I understand that Natural Way Chiropractic, PS may have a contact with my insurance company that allows only co-pays to be collected at time of service. By signing this form, I am agreeing to pay any co-pay, deductible and coinsurance at time of service. This may offer a reduced fee for paying at the time of service rendered.

Patient's Signature*

Date*

Printed name if signed on behalf of patient

Relationship

Personal Injury

Name*

First Last

Today's Date*

Date of Accident*

What time was the accident?*

Weather Conditions?*

Sunny

Clear

Drizzling

Rainy

Foggy

Snowy

Cloudy

Partly Cloudy

Stormy

How were the road conditions?*

Dry

Damp

Wet

Snowed over

Iced over

Dry with ice patches

Do you have a lawyer for this claim?*

Yes

If yes, who?

Vehicle you were in*

Year

Make

Model

Type of your vehicle*

Vehicle size*

Compact

Mid-size

Full-size

Place you were seated in the vehicle*

Driver

Front passenger

Back passenger driver side

Back passenger right side

Back passenger middle

If you were the driver, was your foot on the brake?*

Yes

N/A

Actions of patient’s vehicle*

Crossing intersection

Stopped at an intersection

Stopped for traffic

Stopped for pedestrian

Traveling at posted speed limit

Traveling faster than the posted speed limit

Turning

How was the patient’s vehicle hit?*

Was rear ended

Hit head on

Was hit on the left front

Was hit on the right front

Was hit on the left rear

Was hit on the right rear

Other

Did you have a safety belt on?*

Yes

Shoulder strap?*

Yes

Is your car equipped with Airbags?*

Yes

If yes, did airbags deploy?

Yes

What direction were you going?*

What street was the accident on?*

Nearest cross street*

How fast were you going at the time of accident*

MPH

Did any part of your body strike any part of the vehicle*

Yes

If yes, please explain

Does your vehicle have a headrest*

Yes

What part of your body is the top of your headrest located?*

Neck

Middle of your head

Even with the top of your head

Above top of your head

Other

How aware were you at the time of impact?*

Not aware

Partial

Very

Other

Please explain in detail how the accident happened.*

Describe the Moment of Impact

What position was your body at the time of impact?*

straight

leaning forward

slouched down in seat

turned to the left

turned to the right

bent left

bent right

Other

What direction was your body thrown at time of impact?*

backward then forward

forward then backward

to the left

to the right

outside the vehicle

under the vehicle

Other

What position was your head at time of impact?*

straight

tilted forward

bent left

bent right

twisted/rotated to left

twisted/rotated to right

tilted up

Other

What direction was your head thrown at time of impact?*

backward then forward

forward then backward

bent left

bent right

twisted/rotated to left

twisted/rotated to right

tilted up

Other

Did you feel or hear a popping, tearing, or a ripping noise in your neck or back?*

Yes

If yes, please explain

Did your vehicle strike another vehicle? (was a 3rd vehicle involved)*

Yes

If yes, please explain*

Was the vehicle you were in totaled?*

Yes

Most likely

Unknown

What is the estimated cost of damage of the vehicle your were in?*

What is the second vehicle*

Year

Make

Model

Describe the second vehicle*

What direction was the second vehicle going at the time of impact?*

How fast was the second vehicle going at the time of impact?*

MPH

3rd Vehicle Information (if applicable)*

Year

Make

Model

Describe the third vehicle (if applicable)*

After the Accident

Did the police come to the accident?*

Yes

Was a police report filed?*

Yes

N/A

Were traffic tickets issued?*

Yes

If yes, to whom?

you

the other driver

the driver of your vehicle

Did you lose consciousness after impact?*

Yes

If yes, please explain*

After the accident, were you*

stunned

shook up

shocked

Other

If so, for how long?*

Did you feel any pain*

Yes

If yes, where?*

How soon after the accident did you feel pain*

Is your pain worse in the*

Constant

Same throughout

Did you have, or have you had any numbness, tingling or pain going down arms, hands, legs or feet since the accident?*

Yes

If yes, please explain*

Did you notice any bruising?*

Yes

If yes, where?*

Did you take an ambulance to the hospital after the accident?*

Yes

If yes, what hospital?*

If you did go to the hospital what procedures were done?*

Exam

X-Rays

MRI

Chiropractic Referral

Physical Therapy Referral

Massage Therapy Referral

Other

Were you examined by another healthcare professional after the accident?*

Yes

If yes, by whom?*

When/Date?*

What was done?*

Chiropractic Referral

Physical Therapy Referral

Massage Therapy Referral

Other

Were you prescribed any medication?*

Yes

If yes, what kind(s)?*

Was a diagnosis given?*

Yes

If yes, what did they diagnose you with?*

What have you tried to make your symptoms better?*

ice

heat

stetch

exercise

massage

other

Other

What do you do that make your symptoms worse?*

Have you missed work as a result of this accident?*

Yes

If yes, how many days*

What is your occupation?*

What duties are required of you on the job?*

Have you ever seen a chiropractor?*

Yes

If yes, when and who?*

Have you ever had Spinal X-rays?*

Yes

If yes, when and where?*

What are your current symptoms?*

Compared with before the accident, do you now suffer from*

If other, please explain

Office Policy

Privacy Practices and Releases

Additional Disclosure Authority

Informed Consent

To Our Patients:

Notice of Likelihood of Insurance Denial of Benefits

Assumption of Financial Responsibility

Personal Injury

Describe the Moment of Impact

After the Accident

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