Welcome to our Chiropractic Office! P l e a s e P r i n t C l e a r l y a n d f i l l I n c o m p l e t e l y.

Welcome to our Chiropractic Office! P l e a s e P r i n t C l e a r l y a n d f i l l I n c o m p l e t e l y. Print Name Email Street Address Phone City State Zip Date of Birth Please Check Sex: Male Female Right handed Left handed Married Single Health History: Give reason for seeking chiropractic care: Describe any health problems, including how long you've had them: Are you under the care of any other doctor? Yes No If Yes, the conditions being treated for: List any current Medications: List any past surgeries & dates: List any past accidents & dates: List any x-rays you've had in the past 2 years: Personal & Family History: Your Occupation: Work Duties Spouse s health status Children's ages and health status: Chiropractic History: Have you ever been to a Chiropractor before? Yes No If yes Doctor's Name Date of last chiropractic visit Reason for care Date of last chiropractic x-rays How long were you under care? Are other family members under chiropractic care? - Yes No Who? Wellness Commitment At our office we are dedicated toward achieving the goal of total lasting health for our members. To better help you achieve this, we need to understand your commitment toward being healthy. We do not ask for a financial commitment, but we do ask for your cooperative commitment. Based on a scale of 10% to 100%, please circle your personal level of commitment toward obtaining and maintaining health and wellness. 10% --------20%-------- 30%-------- 40% --------50% --------60%-------- 70%-------- 80% --------90% --------100% Where did you hear about our clinic, or who referred you? FEMALES: Please Check One Is there a possibility of you being pregnant? Yes No

P l e a s e F i l l i n B e l o w If you have had the following, or if you suffer from the following, Please Check Condition, Symptom Or Problem Constantly or Frequently Sometimes or Occasionally Headache Migraines Neck Pain Shoulder Pain Arm/Hand Pain Mid Back Pain Low Back Pain Hip Pain Leg/Foot Pain Disc Problems Arthritis Other joint pain Numbness Joint Swelling Dizziness Nausea Weakness Fatigue Nervousness Insomnia Heart Problems Frequent colds Nose Bleeds Ringing in Ears Earaches Hearing Loss Cough Chest pains Female problems Allergies Asthma Cancer Osteoporosis Diabetes Hypoglycemia Digestive problem Urinary Problems Skin conditions Other Circle the areas where you have any problems. Please also describe these problems. Below, Please Fill In Any Other Health Information You Feel We Might Need For Your Care. Thank you for being complete and thorough. Your Signature Below Please Date:

Discover the Gonstead Difference Patient Policy: Doctor-Patient Agreements Welcome to Spencer Family Chiropractic! The purpose of these agreements is to allow us to more completely serve you and to get the best results in the shortest amount of time. It is our experience that those patients who adhere to the following agreements get the best results. Office Visit When you arrive at the office, please check in, pick up the article of the week and your file. Health Class New patients are required to attend the Thursday night health care class. This report explains how the body functions, how chiropractic works, how the best results are produced, and how to keep your family healthy and well. Our class is given every 2 nd and 4 th Tuesday of the month at 5:30. Reserve your appointment for you and another friend or family member at the front desk. Payment of Bills We will expect you to honor the financial agreements you make with our office. If you find you cannot fulfill the agreement you made with us, advise one of us immediately so new arrangements can be made. Missing or Changing Appointments We will set up a specific course of adjustments for you. A certain number of adjustments are necessary for us to get the results we both desire. Thus, keeping your scheduled appointment is imperative! If you cannot make your scheduled appointment please call us and let us know and we will get you rescheduled. Upsets We are here to serve you and your family. Please speak with one of the Doctors about anything that is upsetting you about our policies or service. We see your comments as helping us to help you and others. Office Hours Your Doctor has specific hours. We will schedule your appointments accordingly. Referrals We ask that you consider us for referrals to your friends and family. It is important to us to deliver the message of true health to the community and we ask for your help in doing so. I have read the above and understand and accept these policies. Patient Signature Date

Spencer Family Chiropractic, INC Chiropractic Financial Program First visit payment of $315 is due at first adjustment (exam-$75, x-rays-$200, adjustment-$40 $40). *We require payment at time of service. **Insurance is accepted, billed and paid back to you by your insurance company. Please provide us with a copy of your card. If you are unable to pay the full amount please refer to payment options #2 and #3 below. Payment Options: please check one. 1. Per visit-cash, check, credit, or debit. 2. Full payment automatically of my balance at the beginning of each month. 3. In effort to provide care for everyone, we offer a monthly payment plan that automatically debits from your credit or debit card account on the beginning of each month. You determine an amount (no less than $75) you would like to have withdrawn. Monthly payment of $ per month beginning 1 st, 2008 automatically. ------------------------------------------------------------------------------------------------------------------ Only payment options 2 and 3 require information below to be completed. I agree to register my Debit Card or Credit Card number confidentially. TYPE OF CARD EXP. DATE NUMBER NAME AS IT APPEARS ON CARD I agree to submit a series of Post-Dated Checks in the amount I have chosen above. BANK NAME ACCOUNT NUMBER ROUTING NUMBER I GIVE PERMISSION TO CHARGE MY DEBIT CARD, CREDIT CARD (INITIALS) OR CHECKING ACCOUNT. SIGNATURE DATE

Financial Policy Please take a few minutes to review the following information prior to your appointment. We hope you understand that our financial policies are established to assure the financial resources needed to maintain this chiropractic office for all of our patients. We will work with you to ensure that your chiropractic care does not become a financial burden. Charges for services are due and payable at the time of service regardless of your insurance status. We accept cash, personal checks, and credit cards for payment on your account. About Health Insurance Your insurance policy is an agreement between you and your insurance company. Our relationship is with you, not with your insurance company. Therefore, all charges are ultimately your responsibility, regardless of your insurance status. PPOs If you have selected Spencer Family Chiropractic because we are on your plan, be aware that we have done this as a service to you in efforts to get you reimbursed for what you pay into your insurance. Regardless of our association with your insurance, whatever amount they do not pay towards our services, you are still responsible for. Signature Date 351 Moraine Ave Estes Park, CO 80517 Phone: 970.577.0007 spencerfamilychiropractic.net

Terms of Acceptance When a person seeks Chiropractic care and we accept a person 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 person understands both the objective and the method that will be used to attain it. This will prevent confusion. Adjustment: A specific application of forces to facilitate the body s correction of the vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. Health: A state of physical, metal and social well being; not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spine resulting in nerve dysfunction, resulting in the lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease. Our focus in this office is the vertebral subluxation. However, if we encounter non-chiropractic or unusual findings we will advise you. If you desire advice, diagnoses, or treatment for the aforementioned findings we recommend that you seek another healthcare 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 locate, analyze and correct vertebral subluxation by specific adjustments. I, have read and fully understand the above statements. (Print name) All questions regarding the chiropractor s objectives to my care in this office have been answered to my complete satisfaction. I therefore accept care on this basis. Signature Date CONSENT TO EVALUATE AND ADJUST A MINOR I, being the parent or legal guardian of have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive Chiropractic care. Signature Date PREGNANCY RELEASE This is to certify that to the best of my knowledge I am not pregnant and the above doctor and her/his staff have my permission to perform X-ray. Date of last menstrual period: Signature Date

Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient s written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to provide care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Name of Patient Date

Identification of Persons with Authorization of Access to Patient Health Information Those individuals or parties that could have access to Patient Health Information at Spencer Family Chiropractic include: The staff of Spencer Family Chiropractic Wellness Center. This includes: 1. Dr. Jill Spencer 2. Dr. Grant Spencer Please provide the necessary health care providers or vendors who may need to be consulted if related to the patient s condition. They include: 1. 2. 3. 4. Signature of Patient Date

Authorization to Contact You It may be necessary for Spencer Family Chiropractic to contact you at home or at work in the event the doctor is out of the office, we need to reschedule, or to remind you of an appointment. By signing below, you give us authorization to contact you for any of the aforementioned circumstances. Signature Date