natural health center · natural health center dr. dan cullum, d.c. (580) 778-3310 420 yucca lane...

Natural Health Center420 Yucca Lane - Turpin, OK 73950

Tel. No. (580) 778-3310 / Cell No. (620) 391-5520 / Fax No. (580) 778-3340

Application for Treatment

Today’s Date _____/______/______

Name:________________________________________ Birthdate:________________ SS#________________Address:________________________________ City:_________________ State:_________ Zip:___________Home Phone No.___________________ Work:___________________ Referred to office by:_______________Cell Phone No. ____________________ Email Address: ____________________________________________Marital Status (please. check one): Married_____ Single_____ Divorced_____ Other_____Employer:__________________________ Address:_____________________ Occupation:_________________

Please Describe The Principle Health Problems or Which You Came To This Office:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How And When Did Symptoms First Occur?____________________________________________________________________________________________________________________________________________________________________________________

List Any Other Doctors Seen For These Problems:__________________________________________________________________________________________

List Diagnosis(es) And Type of Treatment(s):__________________________________________________________________________________________

Does The Interfere With Your Normal Living And Work? Yes_____ No_____If Yes, Explain:______________________________________________________________________________

List Names o Relatives That Have Or Have Had A Similar Problem:__________________________________________________________________________________________

Who is Responsible or Your Bill? (please. Check)Self_____ Spouse_____ Employer_____ Automobile Insurance_____ Workman’s Compensation_____Cash_____ Check_____ Visa_____ Mastercard_____

If Automobile Ins. Or Workman’s Comp / Name And Address And Policy Number:__________________________________________________________________________________________

Past History

Have You Been Treated For Any Health Condition By A Physician In The Last Year? Yes_____ No_____If Yes, Explain:______________________________________________________________________________

Have You Or Any Relative Received Chiropractic Treatments Previously? Yes_____ No_____If Yes, Explain:______________________________________________________________________________

List The approximate Dates Of Any Operations, Unusual Diseases, Serious Illnesses Or Accidents You Have Had (Include Broken Bones):__________________________________________________________________________________________

List All Drugs Or Medication That You Have Used Recently (I.E. Aspirin, Sleeping Pills, Birth Control Pills, Etc.)______________________________________________________________________________________________________________________________________________________________________________________________________

Family History

Name Of Spouse:_________________________________ Ages Of Children:_________________________________Spouse’s Employer:________________________________ Business phone:______________________Your Nearest Relative:_____________________________ Address:_____________________________

Please Mark Your Areas Of Pain List Conditions That You Are Most(with an X) On The Figures Below: Interested In Getting Corrected.

List In Order Of Importance:1. _______________________________________2. _______________________________________3. _______________________________________4. _______________________________________

What Functions Are You Unable ToPerform Or That Induce Pain: (I.E. Sitting,Standing, Walking, etc.)List In Order of Severity.1. _______________________________________2. _______________________________________3. _______________________________________4. _______________________________________

FEES ARE PAYABLE AT THE TIME X-RAYS, EXAMINATIONS AND TREATMENTS ARE RECEIVED UNLESS OTHER ARRANGEMENTS ARE MADE IN ADVANCE. X-RAYS REMAIN THE PROPERTY OF THIS CLINIC. I HEREBY GIVE PERMISSION OF TREATMENT. I HEREBY AUTHORIZE THE USE OF METHODS DEEMED NECESSARY BY DR. CULLUM.

________________________________________ _________________________________________Signature Of Patient Or Guardian Social Security Number

Natural Health CenterDr. Dan Cullum, D.C.

(580) 778-3310420 Yucca Lane

Turpin, OK 73950

My signature below indicates I understand that I am responsible for the balance in full for services I received here at Natural Health Center. We do not accept any insurance assignment. I am responsible for filing my own insurance so that they may reimburse the services I received.

____________________________ ________________Signature Date

Natural Health CenterDr. Dan Cullum, D.C.

420 Yucca LaneTurpin, OK 73950

(580) 778-3310

Cancellation policy

Due to the nature of our practice we require 24 hour notice for all cancellations. If you fail to provide adequate notice your account will be charged a service charge. Also, if for any reason you should miss your appointment with no notification a service charge will be added to your account. Your signature below indicates that you understand and are responsible for these fees if they should occur.

____________________________ ________________Signature Date

Natural Health CenterDr. Dan Cullum, D.C.

420 Yucca LaneTurpin, OK 73950

(580) 778-3310

Notice of Privacy PracticesPatient Acknowledgment

Patient Name:_____________________________________________________________________

Date of Birth:__________________________________________

I have received and understand this practice’s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice’s legal duties with respect to my information.

I understand that this practice reserves the right to change the terms of the Notice of Privacy Practices, and to make changes regarding all protected health information, resident at, or controlled by, this practice. If changes to the policy occur, the practice will provide me a revised Notice of Privacy Practices upon request..

Signature:_____________________________________________________________________

Date:__________________________________________

Relationship to patient (if signed by a personal representative of patient):

_____________________________________________________________________

NATURAL HEALTH CENTERDAN CULLUM, D.C.based420 YUCCA LANETURPIN, OKLAHOMA 739501-580-778-3310

Request and Consent For Treatment

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures. Including but not limited to, various modes of physical modalities and diagnostic x-rays on me, (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named above and/or other licensed doctor of chiropractic, who now or in the future treat me while employed, working, or associated with, or serving as back up for the doctor of chiropractic named above, including those working at the clinic or office listed below or any other office or clinic.

I have had an opportunity to discuss with the doctor of chiropractic, named above and/or with other office or clinic personnel, the nature and purpose of chiropractic and other procedures. Including that the results are not guaranteed.

I understand and am informed that, as in the practice of medicine as well as in the practice of chiropractic there are some risks to treatment, including but not limited to, fractures, injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. I wish to rely on the knowledge of the doctor of chiropractic named above to exercise his judgment during the course of the procedure, based upon the facts that are then known, is in my best interest.

I have read or have had read to me the above consent. I have also had the opportunity to ask any questions about this consent. By signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present conditions and/or any future conditions for which I seek treatment from the doctor of chiropractic named above..__________________________________________________________________________________Print Patients Full Name

__________________________________________________________________________________Patients Signature Date

__________________________________________________________________________________Print Patients Authorized Representatives Name

__________________________________________________________________________________Patients Authorized Representatives Signature Date

__________________________________________________________________________________Authorized Representatives Relationship To Patient

__________________________________________________________________________________Print Patients Full Name