Highlands Sport and Spine 3801 Osage Street Denver, CO 80211 Tel: (303) 955-5994 Fax: (303) 993-2681 Email: sportandspinehighlands@gmail.com Website: sportandspinehighlands.com

CHART ID Number:

DR: JW

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Confidential Patient Information

Patient’s Full Name________________________________________________________________ Date:_____/_____/_____

Home Phone: ______________________ Cell Phone: _____________________

Mailing Address:____________________________________________ City:________________ State:_______ Zip:_____________

E-Mail: __________________________________________________ Male/Female/Non-Binary Pref. Pronouns_______________

Date of Birth:_____/____/______ Social Security # ________ - ________ - ________

Employment Information:

Occupation:_________________ Hours/Week_______ Employer:______________________ Business Phone__________________

Spouse’s Name:_______________________ Employer:______________________________ Business Phone__________________

Emergency Contact:__________________________Relationship:______________________ Phone: ________________________

Address:_________________________________ City:________________________ State:______________ Zip: ________________

Concurrent Health Care

Are you currently receiving treatment for this problem? Yes / No

Family Physician: _______________________ City: ________________________ State:____________ Phone_________________

Would you like us to keep your family physician informed with a letter? Yes / No

Have you had previous chiropractic care: � Yes � No If Yes, for what Problem: _________________________________________

Who referred you to us? ______________________________How else did you hear about us?_______________________________

Insurance Information:

Do you have health insurance? � Yes � No Company Name_____________________________________________________

Is Today’s Visit Due To A Work Related Injury: � Yes � No

Is Today’s Visit Due To A Personal Injury or Auto Accident: � Yes � No

(If yes to either questions above, please check with receptionist, additional information is needed)

Date Of Injury:________________ Person Responsible for Account: ___________________________ Phone: ________________

Address:______________________________________ City:_________________ State:________ Zip: _______________________

AUTHORIZATION AND ASSIGNMENT: In consideration of your undertaking to care for me, I agree to the following:

1. You are authorized to release any information you deem appropriate concerning my physical or emotional condition and/or health history toany insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred.2. I authorize the direct payment to you of any sum I now or hereafter owe you by my attorney out of the proceeds of any settlement of mycase, and by any insurance company obligated make payment to me or you based in whole or in part upon the charges made for your services.3. In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges made for yourservices refuses to make such payment upon demand by you , I hereby assign and transfer to you the cause of action that exists in my favoragainst any such company (the name(s) of which is believed to be correctly set forth under pertinent data) and authorize you to prosecute saidaction either in my name as you see fit and further authorize you to compromise, settle, or otherwise resolve said claim as you see fit. However, itis understood that all reasonable efforts have been made to collect the sums due from the insurance company, or companies, contractuallyobligated, you will refrain from attempts and efforts to collect the amounts owed directly from me. I understand that whatever amounts you donot collect from insurance companies proceeds, whether it be all or part of what was due, I personally owe you.4. In addition to the above, I hereby waive the statute of limitations on collection and/or recovery in this state of Colorado5. I further agree that this Authorization and Assignment is irrevocable until all moneys owed Highlands Sport and Spine are paid in full.

Patient Signature__________________________________________ Date__________ Page 1 of 4 OVER →

Dear Patient: Please complete this brief health questionnaire. If you need assistance, please ask. Your answers will help us determine how

chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case.

THANK YOU.

Patient’s Name: ____________________________________________________________ Date:______/_______/_______

Chief complaint_____________________________________________________________________________________________

Secondary or related complaint if any:_________________________ __________________________________________________

Third or related complaint if any:________________________________________________________________________________

Date of Onset: ________________________ Was the Onset � Gradual � Sudden Since onset, has it gotten: � Worse � Better

Describe what caused the pain:_____________________ __________________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS

TO HELP EXPLAIN THE PROBLEM:

YOUR CHIEF COMPLAINT:

Describe the quality of the complaint/pain: Does any of the following make the pain worse:

� sharp � lifting/bending/pushing/pulling

� dull/ache � cough/sneeze/bowel movement

� throbbing � driving/riding/sitting

� tingling/numbness � walking/running/standing

� other:_______________________________ � other:_______________________________

Describe if pain is in a single spot or does is spread out: Does any of the following make it better:

� radiating dull, deep ache � rest/laying down

� pin point � sitting

� burning, sharp stabbing, tingling, numb � walking/exercise

� other:_______________________________ � other:_______________________________

How often are you aware of the pain: Does it interfere with your daily activities:

� intermittent (less than 25% of time when awake) � minimal (annoyance, no impairment)

� occasional (25-50% of time when awake) � slight (tolerated, some impairment)

� frequent (50-75% of time when awake) � moderate (marked impairment)

� constant (75-100% of time when awake) � marked (preclude any activity)

Have you detected any possible relationship of your current complaint with any of the following?

� Muscle Weakness � Bowel/Bladder problems � Digestion � Cardiac/Respiratory � Other:______________________________

Have you tried any self-treatment or taken any medication (over the counter or prescription): � Yes � No

If yes, explain;_______________________________________________________________________________Results:_____________________

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Please Mark Areas of Pain using these Codes +++ Burning ### Dull/Ache *** Numbness/Tingling

=== Throbbing 000 Stabbing/Sharp

SEVERITY OF PAIN:

List region of pain and circle the number which represents the

intensity of your pain.

1. Complaint: __________________ 0 1 2 3 4 5 6 7 8 9 10no pain unbearable

2. Complaint: __________________ 0 1 2 3 4 5 6 7 8 9 10no pain unbearable

3. Complaint:___________________ 0 1 2 3 4 5 6 7 8 9 10no pain unbearable

Past Health, Social and Family Health History: Patient Initial __________Date ______________

1. In general, would you say your health is (check one): � Excellent � Very good � Good � Fair � Poor

2. Have you ever experienced your present problem before for which you are consulting us: � Yes � No If yes, When:___________

3. Was treatment provided: � Yes � No If yes, By whom:_______________________________ Outcome:____________________

4. Have you ever had any major illnesses, injuries, broken bones, hospitalizations, accidents, or surgeries? � Yes � No If Yes

please list them:

Date Injury / Fracture / Illness Treatment Results

5. Is there any history of significant health problems in your family?

Relative Age if Living State of Health Illnesses

Grand Parents

Father

Mother

Siblings

6. Current Weight_________lbs Have you recently lost or gained weight? � Yes � No Approximate Height________________

7. Do you regularly exercise? � Yes � No If yes, how many hours a week and what activities _____________________________

8. Do you smoke? � Yes � No If yes, how many pack/day? _________

9. Do you drink alcohol? � light �moderate � heavy How many glasses per week? _________

Thank you for filling out the above information

Medication List:(Please list all medications you are currently taking or have been taking within the past year)_______________________________________________________________________________________

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Please read and Sign the below form before examination and treatment

INFORMED CONSENT

Medical doctors, chiropractic doctors, osteopaths, and physical therapists that perform manipulation are required by law to obtain your informed

consent before starting treatment.

I______________________________________________, Do hereby give my consent to the performance of conservative noninvasive treatment

to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft

tissues. Physical therapy and exercises may also be used. Although spinal and extremity manipulation/adjustment is considered to be one of the

safest, most effective forms of therapy for musculoskeletal problems, I am aware the there are possible risks and complications associated with these

procedures as follows:

Soreness/Bruising: I am aware that like exercise it is common to experience muscle soreness and occasionally bruising in the first few treatments.

Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare.

Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies like weak bones from

osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will

proceed with extra caution.

Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are rare. I am aware that nerve or brain

damage including stroke is reported to occur once in a million to once in ten million treatments. Once in a million is about the same chance as getting

hit by lightning. Once in ten million is about the same chance as a normal dose of aspirin or Tylenol causing death.

Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is

obtained, there will be a temporary increase in pain and possible blistering. This should be reported to the doctor. Tests have been or will be

performed on me to minimize the risk of any complication from treatment and I freely assume these risks.

TREATMENT RESULTS

I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and

function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits.

I realize that the practice of medicine, including chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me

Regarding the outcome of these procedures. I agree to the performance of these procedures by my doctor and such other persons of the doctor’s

choosing.

ALTERNATIVE TREATMENTS AVAILABLE

Reasonable alternatives to these procedures have been explained to me including, rest, home applications of therapy, prescription or over-thecounter

medications, exercises and possible surgery.

Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use or overuse of medication is always a cause for

concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side effects, physical or psychological dependence, and

may have to be continued indefinitely. Some medications may involve serious risks.

Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and

pain. The same is true of ice, heat or other home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Exercises are of

limited value but are not corrective of injured nerve and joint tissues.

Surgery: Surgery may be necessary for joint instability or serious disc rupture. Surgical risks may include unsuccessful outcome, complications,

pain or reaction to anesthesia, and prolonged recovery.

Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion,

possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery

and rehabilitation more difficult and lengthy.

NO SHOW AND LATE CANCELLATION POLICY Our no show/late cancellation policy requires 24 hour notice if you are unable to make your appointment. If no notice or less than 24 hours notice is given, there will be a $30 fee.

I have read or had read to me the above explanation of chiropractic treatment and no show/late cancellation policy. Any questions I have

had regarding these procedures/policy have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have

made my decision voluntarily and freely.

To attest to my consent to these procedures/policy, I hereby affix my signature to this authorization for treatment.

___________________________________________Signature of Patient Date_____________________________

___________________________________________Signature of Parent or Guardian (if a minor) Date_____________________________

___________________________________________Signature of Witness Date_____________________________

TRIGGER POINT DRY NEEDLING CONSENT FORM

Trigger point dry needling (TDN) involves placing a small fusiform needle into the muscle at the trigger point in order to cause the muscle to contract and then release, improving the flexibility of the muscle and therefore decreasing the symptoms.

TDN is a valuable treatment for musculoskeletal pain. Like any treatment there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving consent to treatment. Trigger point dry needling is not intended to stimulate any distal or auricular acupuncture points.

Risks of the procedure:

The most serious risk associated with TDN is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely only require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture can require hospitalization and re-inflation of the lung. This is a rare complication and in skilled hands should not be a concern.

Other risks may include excessive bleeding (causing a bruise), infection and nerve injury. Bruising is a common occurrence and should not be a concern unless you are taking a blood thinner. As the needles are very small and do not have a cutting edge, the likelihood of any significant tissue trauma from TDN is unlikely.

Please consult with your practitioner if you have any questions regarding the treatment above.

Currently Jonathan Weimer DC, MS, CCSP has completed 46 of the 46 hours required by the Colorado Department of Regulatory Agencies.

I have read or been read and understand the above information, and hereby give consent for Trigger Point Dry Needling procedures to be performed on me by Jonathan Weimer DC, MS, CCSP. This consent may be revoked at any time verbally or in writing.

Signature

_______________________________

Date

_____________

Printed name

_______________________________

HIGHLANDS SPORT AND SPINE

PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

__________________, hereby states that by signing this Consent, I acknowledge and agree as follows:

1. The Practice's Privacy Notice has been provided to me prior to my signing this Consent. ThePrivacy Notice includes a complete description of the uses and/or disclosures of my protectedhealth information ("PHI") necessary for the Practice to provide treatment to me, and also necessaryfor the Practice to obtain payment for that treatment and to carry out is health care operations. ThePractice explained to me that the Privacy Notice will be available to me in the future at my request.The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signingthis Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing thisConsent.2. The Practice reserves the right to change its privacy practices that are described in its PrivacyNotice, in accordance with applicable law.3. I understand that, and consent to, the following appointment reminders that will be used bythe Practice: a) a postcard mailed to me at the address provided by me; and b) telephoning my homeand leaving a message on my answering machine or with the individual answering the phone.4. The Practice may use and/or disclose my PHI (which includes information about my healthor condition and the treatment provided to me) in order for the Practice to treat me and obtainpayment for that treatment, and as necessary for the Practice to conduct its specific health careoperations.5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practiceis not required to agree to any restrictions that I have requested. If the Practice agrees to a requestedrestriction, then the restriction is binding on the Practice.6. I understand that this Consent is valid for seven years. I further understand that I have theright to revoke this Consent, in writing, at any time for all future transactions, with the understandingthat any such revocation shall not apply to the extent that the Practice has already taken action inreliance on this consent.7. I understand that if I revoke this consent at any time, the Practice has the right to refuse totreat me.8. I understand that if I do not sign this Consent evidencing my consent to the uses anddisclosures described to me above and contained in the Privacy Notice, then the Practice will nottreat me.

I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.

____________________________

Name of Individual (Printed) ____________________________ Signature of Legal Representative (e.g. attorney-in-fact, guardian, parent if minor)

____________________________Date signed

_____________________________

Signature of Individual _____________________________

Relationship

_____________________________

Witness

Patient Acknowledgement Form for Non-Covered Services, Products and Other Situations

Material developed with the help of Keith Pendelton, JD, on legal aspects related to this form. © 2014 KMC University / Kathy Mills Chang, Inc. All Rights Reserved.

Your health insurance plan requires you to be responsible for co-payments, co-insurance and deductibles for covered services and products as well as those services/products that exceed certain benefit limits. You are also financially responsible for all non-covered services and products, as well as any product we provide whose allowed fee is less than the purchase price to our office associated with the product.

Your health insurance plan either does not cover the product type or service noted above, or allows less than the purchase price associated with the product/service we provide. Your acknowledgement below indicates that you have been advised of this information and that you agree to pay the office’s charge.

Patient Acknowledgement:

I (patient name), acknowledge that I have been told in advance by this office that my health insurance plan either does not cover the product listed above or pays less than the purchase price associated with the product we provided, and I agree to pay for this product at the time it is of service. I have been told that there may be other products available at lower purchase prices that still meet my insurance plan’s medical necessity requirements.

Patient Signature: Date:

Patient Name:

PRODUCT OR SERVICE REASON FOR NON-COVERAGE PATIENT RESPONSIBILITY

Trigger Point Dry Needling Non covered service by insurance $20 per unit

Active Release Techniques (ART) Non covered service by insurance $20 per unit

Instrument Assisted Soft Tissue Mobilization Non covered service by insurance $20 per unit(IASTM)

Taping Non covered service by insurance $5 - 1 area/unit$10 - 2 areas/units

Highlands Sport and Spine 303-955-5994 sportandspinehighlands.com

Dear Patient,

We have exciting news!

We are pleased to announce our partnership with Colorado Integrated Care Network (CICN). As a member of CICN, a greater range of our services are now eligible for coverage by most major insurance plans. The Benefits to you: We are in-network with nearly all major insurance companies! As a member of CICN we are now in-network with most policies provided by: Cigna, United Health Care, UMR, Humana, Aetna, Anthem Blue Cross/Blue Shield, Rocky Mountain Health Plans, and each of their subsidiaries.

A greater range of covered services means more comprehensive care! Nearly all of the services offered in our clinic can be billed to your insurance company. Ask us for details!

VERY IMPORTANT: Effective for dates of service billed after November 1st, 2018, your insurance’s explanation of benefits (EOB) will list Colorado Integrated Care Network and the name of our assigned Medical Director/Billing Provider, Dr. Michelle Smith

We are extremely excited for the opportunity to be a part of the CICN network. After seeing the many ways CICN benefits you and our clinic, we think you will feel the same. For more information about CICN please visit www.cointegratedcare.com.

I, _______________________ (please print), understand that my insurance company’s explanation of benefits (EOB) will list Colorado Integrated Care Network and the name of Highland Sport and Spine’s medical Director/Billing Provider, Dr. Michelle Smith in reference to the services received at Highlands Sport and Spine.

Signed,

____________________________________ Date_________

(Cardholder’s Name)

(Cardholder’s Signature)

Credit Card Authorization Form

Credit Card Type Visa MC Disc AmEx

Credit Card Number _____________________________

Exp Date ___/___ CCV ____

Cardholder’s Name _____________________________

Billing Address _____________________________

_____________________________

City, State & Zip _______________, ____ ________

By signing this form I, ____________________, authorize Highlands

Sport and Spine to keep my credit card number on file to be used for future transactions, patient appointments, RAD products, etc. I maintain the understanding that HSS will notify me of the amount prior to running my card, in the event I have questions about the charges or decide to be considered self-pay (vs insurance).

I certify that I am an authorized user of this Credit Card and will not dispute the transactions; so long as the provisions above are met.

Authorized Signature ___________________________ Date ___________

Highlands Sport and Spine No Show/Late Cancel Policy

By signing below, I have agreed to follow in Highlands Sport and Spine’s No Show and Late Cancel Policy. I acknowledge that not showing up to a scheduled appointment or cancelling an appointment with less than 24 hours’ notice will give Highlands Sport and Spine the authority to charge me $30 for each appointment. I understand weather and personal emergencies will be evaluated by Highlands Sport and Spine on an individual basis.

I hereby waive, release, and authorize Highlands Sport and Spine to process payment of my card for no show or late cancel fees.

Signature ___________________________________

Print Name __________________________________

Date ____________