Today's Date: NEW PATIENT APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help, please ask the front desk or call the office if filling out at home (865-896-9159). PLEASE PRINT. Last Name: First Name: Middle Initial: Age: Date of Birth: / / Marital Status: S M W D Social Security: - - Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Street Address: City: State: Zip: Email Address: * How did you hear about our office? Preferred Language: Number of Children: Ages: Emergency Contact: Phone Number: ( ) - Relationship to Emergency Contact: Your Employer: Status: Full Time or Part Time (circle one) Occupation: Time at Job: Employer Street Address: City: State: Zip: Job Descriptions (Standing? Sitting? Heavy Lifting? Computer Work?) Insurance Provider: Policy Number: Do you have Medicare? Yes No (If yes, please provide primary insurance card and photo ID) Name of Spouse or Parent: Date of Birth: / / Spouse Employer: Status: Full Time or Part Time (circle one) Occupation: Time at Job: Employer Street Address: City: State: Zip:
Is your condition due to an accident? Yes No Date of accident? / / Type of accident? Auto Work/On Job At Home Other Have you ever been in an auto accident or other type of accident? Yes No Past Year Past 5 Years Over 5 Years Never Describe accidents/traumas: Are you on any Medications right now? Yes No List Medications: Side Effects: Do you have any allergies? Have you had any surgeries? (Include date) Any residual effects? COMPLETE THE DIAGRAMS If you are in pain, please mark the exact location of your pain on the diagram. Also describe the type and frequency of your pain, as well as any activity which brings on or aggravates the pain. For example: dull, sharp, consistent, off & on, when standing, when sitting, etc. If condition is not pain related, please describe as best as possible. MAJOR COMPLAINTS (Please list any condition you are being treated for or are experiencing) Rate pain: 0 1 2 3 4 5 6 7 8 9 10 (Worst pain ever experienced) Social Habits: Drink Alcohol? Yes No How many drinks a week? Drink Caffeine? Yes No What type? How many per day? Smoke? Yes No How often? You should be receiving text reminders for you appointments. If you are not receiving these messages or would like to be removed from our text reminder list, please inform a staff member at the front desk.
I (we) agree to pay for services rendered to the above mentioned patient. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself and that I am personally responsible for payment of any and all services covered or not covered. I also understand that if I suspend or terminate my care and treatment, any fee for professional services rendered me will be immediately due and payable. Patient Full Name (printed): Patient's Signature: Date: / / Or Guardian Signature: Date: / / Please check all present and/or past symptoms or complaints that apply: ADD/ADHD Alcohol/drug addiction Anemia Appendicitis Arrhythmia Arteriosclerosis Arthritis Asthma Backaches Bleeding disorder Blood clots Blood transfusions Blurred vision Bowel problems Broken bones Cancer Carpal tunnel Cataracts Chicken Pox Cold sores Colitis Diabetes (Check type) Type I Type II Collagen vascular disease Constipation Depression/anxiety Digestive disorders Dizziness Eating disorder Emphysema Epilepsy Fatigue Female health challenges Fibromyalgia Gallbladder disease Genital herpes Glaucoma Gluten intolerance Goiter Gout Headaches Hearing loss Heart disease/attacks Heart murmur Hemorrhoids Hepatitis (A B C D E ) High blood pressure High cholesterol HIV/AIDS Joint/back pain Kidney infections Kidney stones Liver disease/problems Lung disease Measles Menstrual cramps Mental disorder Migraines Miscarriage Multiple sclerosis Neck pain Nervousness Night sweats Osteoporosis Paralysis Pneumonia Polio Prostate problems Reflux/ulcers Rheumatic fever Scoliosis Seizures/epilepsy Sexual dysfunction
Sickle cell Sinus trouble Stress/tension Stroke Suicidal tendencies Thyroid disease Tuberculosis Tumors Ulcers Urine discoloration Vertigo Whooping cough If your condition is not listed above, please list below. Give a brief explanation on any listed above if needed. MEDICAL RELEASE FORM (HIPPA RELEASE FORM) Patient Name: Date of Birth: / / RELEASE OF INFORMATION I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. The information may be released to the following: Spouse: Child(ren): Other: Information is NOT to be released to anyone. *This Release of Information will remain in effect until terminated by me in writing MESSAGES Please call: My home phone My work phone My cell phone If unable to reach me: Please leave a detailed message Please leave a message asking me to return your call The best time of day to reach me is (day) Morning Afternoon Patient/Guardian Signature: Date: / / Witness Signature: Date: / /
HIPAA Privacy Act By signing, I state that I have been provided with the HIPAA Privacy Act information in the form of a pamphlet. Patient Name (Printed): Date: / / Signature of Patient or Legal Guardian: If Legal Guardian, Relationship to Patient: Print Name of Legal Guardian: CONSENT FOR TREATMENT AND AUTHORIZATION TO PERFORM X-RAYS Date: / / Time: AM / PM I have been informed by Dr. Harper that diagnostic x-rays are advisable in my case so that a complete analysis can be made of my present musculoskeletal problems (or illness). I authorize Dr. Harper to perform such radiographic examination necessary to diagnose, and to administer whatever treatment is deemed necessary to treat my present problem (or illness) Patient Signature: Witness Signature: To the best of my knowledge, I am NOT pregnant and the above named Doctor has my permission to x-ray me for diagnostic interpretation. Patient Signature: CONSENT TO TREATMENT OF A MINOR CHILD (Patients birth to 18 years old) I herby authorize Dr. Harper, and whomever he may designate as assistants to administer chiropractic care as deemed necessary to (name of child). My relationship to child: Dated at, (City) (State) The day of, 20 (Day) (Month) (Year) Parent or Guardian Signature: Witnessed Signature:
CHILD SUPERVISION POLICY (Children birth to 18 years old) Please do not leave children unattended; children must be with parents at all times while in the office. Please keep children quiet while in the office (we have patients resting and don't want to disrupt them). Resting tables and massage chairs are for patients only (unless told otherwise by Doctor or staff member). Employees only behind the front desk I have acknowledged the above policies Patient (or Guardian) Signature: Date: / / LATE AND MISSED APPOINTMENT POLICY At Southeast Precision Clinic of Chiropractic, we put our faith in you to keep your appointment. When we set up an appointment, a specific amount of time is reserved especially for you. Many offices double or even triple book appointments. However, double booking appointments does not allow us to give the attention needed to provide excellent quality care and for this reason we choose to not do that. We have a waiting list each day for call-in appointments. Knowing ahead of time allows us to fill those spots. If for any reason you must cancel or change your appointment, it is important that you give our office at least 24 hours notice to offer that spot to someone else. 1 st Missed Appointment: If an appointment is missed or canceled within the 24 hour window, a letter will be sent to your home and we will call you reminding you of our policy. We also reserve the right to charge you $50 for this missed appointment. 2 nd Missed Appointment: After your second missed appointment, another letter will be sent to your home notifying you of a change in status of your account. $50 will be applied to your account as a missed appointment fee. If you do not pay this fee, you will not be able to make another appointment until you have done so. We understand that true emergencies happen. If this is the case, please provide us with a doctor's note or other adequate proof and the missed appointment will be removed from your account record. Late arrival: When we reserve time for you, we require all of that time to provide you with the best quality care possible. When you are late, it decreases our ability to accomplish this. If you arrive more than 15 minutes late, your appointment may be rescheduled in order to meet the needs of those you are on time for their prereserved visit. If this happens, it will be considered a missed appointment. You are welcome to wait for an available spot on the schedule if the staff is able to work you in. Get Out of Jail Free Card: This means you get two late or missed appointments with no charge to you at all. However, after those two you will be charged on the missed appointment fee schedule as noted above.
I have read the policy above. I understand and agree to abide by the listed terms. Patient Name (Printed): Date: / / Signature of Patient or Legal Guardian: