New Patient Registration Form
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1. Patient Information
* indicates required field
Height*:
Weight*:
Sex*:
Date of Birth*:
Address*:
Address*:
Are you the primary insured?
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2. Case History
Major
dull ache?
numbness?
tingling?
Has this happened before?*
Does this interfere with your normal activities and/or work?*
Any family history of this condition?*
Any work related accidents in the last 4 years?*
Any car accidents in the last 4 years?*
Do you smoke?*
Are you presently taking any nutritional supplements?*
Have you been treatment by another doctor for this?*
If so, what type of doctor?
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3. Health Questionaire
Please make a selection for every field.
Musculo-Skeletal System
Arm problems
Leg problems
Swollen joints
Painful joints
Sore muscles
Stiff joints
Weak muscles
Walking problems
Ruptures
Broken bones
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Eye, Ear, Nose & Throat
Eye strain
Eye inflammation
Vision problems
Ear pain
Ear noise
Ear discharge
Hearing loss
Nose pain
Nose bleeding
Difficult breathing
Through nose
Sore guns
Dental problems
Sore mouth
Sore throat
Hoarseness
Difficult speech
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Gastro-Intestinal System
Difficult chewing
Difficulty swallowing
Excessive thirst
Nausea
Vomiting blood
Abdominal pain
Diarrhea
Constipation
Black stool
Bloody stool
Gall bladder probs
Weight trouble
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Nervous System
Numbness
Loss of feeling
Paralysis
Dizziness
Fainting
Headaches
Muscles jerking
Convulsions
Fogetfulness
Confusion
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Genito-Urinary System
Bladder trouble
Exessive urination
Scanty urination
Painful urination
Discolored urination
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4. Assignment of Benefits
I authorize the release of any medical or other information 'necessary to process my claims. I also request payment of government benefits either to myself or to the party who accepts assignments below.
I authorize payment of medical benefits to the undersigned physician or supplier for the appropriate medical services.
PLEASE REMEMBER THAT INSURANCE IS CONSIDERED A METHOD OF REIMBURSING THE PATIENT for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance company. I understand any unpaid balance within 30 days will result in an additional 1% interest charge. If this account is assigned to a collection agency, an additional fee of 40% of amount owed will be added.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance.
Click here to indicate you have read and agree to the Assignment of Benefits stated above.
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5. Chiropractic Consent
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes, of physical therapy and diagnostic x-rays, on me (or on the patient named below, for, whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors' of chiropractic who now or in the future treat me while employed by, working, associated with, or serving as back up for the chiropractor named below, including those working at the clinic or office listed below or any other office or clinic associated with Pavlik Chiropractic.
I have had an opportunity to discuss with the doctor of chiropractic named below the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.
I understand and am informed that, as in tile practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content and by signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatrnent for my present condition(s) and for any future condition(s) for which I seek treatment.
Click here to indicate you have read and agree to the Chiropractic Consent stated above.
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6. Privacy
Agreement
Our office is fully compliant with HIPAA (the Health Insurance Portability and Accountability Act of 2002) and as such we will do our best to protect the privacy of your medical information, both paper and electronic, and will in most circumstances only release what is needed for medical treatment and insurance payments. Our privacy policy is posted in the waiting room and a copy is available for you at the front desk at your request.
Click here to acknowledge that you have reviewed the Notice of Privacy Practices from Pavlik Chiropractic / Access Healthcare of Orlando.
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Click the button below to submit your registration information.
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