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