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Saudoz Chiropractic Center2057 Briggs Road Suite 204}lount Laurel, NJ 08054Prl 856-206-9560 Fax: 856-206-970I59'5'.sandozcbiropractic.conrft ogdesk@sandozchirOpra_ct!c c. gnr

First Name: Middle: Last:

Preferred Natne: Maiden Name:

Race (choosc one): [Asian] lAfrican American] [Caucasian] [llispanic] [Natirc Anrerican] [Other]Ethnicity (choose onc): INon-llispanic] [llispanic] [Withheld]

Addrcss: Postal Code:

City State: E-mail address:

Appointmenr raninder preference: [Cell Phone Call] [Home Phone Calll [Text Messagel [E-mail](Circlc more than one above ifyou would prefer that)

llome Phonc Work Phonc Cell phone

Cell phonc carrir:r (for tcxt mcssages) [AT&T] [Verizon] [Sprint] [Virgin] Other

Gender: [Male] []'emalel lleight: {l in Weight: lbs.

Manicd Single l)ivorced Widow(cr) Number of Children Pregnant: Due Date;

Employer Ocrupation

Iimergcncy Contarl: Contacl Phone #

Whorn may we thank for rcferring you'l

Primary Carc Doctor: Phone;

Chiropractors you havc scen before:

Name City State Wheo

List all accidents or injuriel:

Type When flospitalizd?

List all surgenes:

Type wh€n

List medicstions aodlor vitamirrs and supplements you are takhg

Name For -Itow long

Name For How loug

Use back of*tcd for any addiEonal sprce needed.

S8ldoz Chiropec{ic Ccatc, - ptorc: E5G20G9S60 F!x: E56-206-9?01front&k(gradozchieon€tic"com ywy,caadozchirqFactb.cqn

\t'elcome 'I o Sandoz Cbirooractic Center( lOn* F-l Dll,N'l'I A L PA'I'I UNI' tN t'ORII{A'I'ION FORItt - Pt,IiASI PRI N't'

Name:

PAIN DRAWING

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Please bc sure to fill this out extrcmely accurately. Mark thc area on your body rvhcre you feel thcdescribed sensation(s). use the appropriate symbol(s), rnark the area ofradiating pain, and includc allaffccted arcas. You may drarv on thc facc as well.

Paio Strtbols:

Numbness

Pins & Needlcsooooooo

tlurning Painxxxxxxxx

Stabbing I'airr

Aching Pain(((((((((

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Chief Complarnt.

Patienl Explanation of lrrcident

Date ofOnsctOn the Job:Auto Accidcnt:

YesYes

Did s).mptoms appear gradually or suddenly?No Days offwork:

No Days offwork:

Sandoz Chiropractic Cente! - Phorc: E56-206-9560 Fax: 856-20G9701&S!Laesk&!SStloZ.!t!!qp!?ette-es_r lrtw€fr&Zdri!9lrCels.gqg

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Bclow are listed corrunon s)nnptoms rvhich may suggcst the presorcc ofan ailmenl involving aparticular body system. lf you evcr had a listed symptom in thc past, pleasc check that synptom in tlreleft hand column. If you are prescntly troubled by a pa(icular symptom. chcck that symptom in theright hand colunrn.

Prc'r:nlPaii Iths.nlo3l.l.{.lN.* poinShoulhr painPain in trppcr omr or clborvlland painUplcr blc* paar'

t.orv b.& piinPlin in !np6 lc8 or hi!Plin in lorvcr lcg o.lnc{-Pah in lnklc o{ fm.Jav prinS\tcllioS io rointr (l'!r roint')

tl StilTiss ofjorms (Irljoinrr) I I

llerror! SyllantDqx!:rsionlnsonniaBcr, rrcttingfairtintConlulsionsDi,,zincrsllcadaclrcMuscl,lff incoor.lrnationHe.rirg lorsTinnitus (car nr}rsls)[ar painlmpain{ rison[yc pnillPar.l)5ir

Cardiorr5culrtRnpid hsrn*L,r'CllFi lrins

Eodocri6.arrs ofofi*ttcAbnonri.ll Ncight gainAbnonnrl wcight lors

ast Co.dition

Hcon discasalligh blood prcisurcAntinallca.t ar.clStrokc

Gsllblrddcr(b.1crY

Rc{irotorySlprtrcs of bn:thChronic painChronic corghChronic si[usiri5

Gy!arologl.Pain during omstruarror,lrrtgular mcn.trucl fl ouSFltinSIllni|Pnu.nl tlnpknn.

Gl Tn(tAbdrxniml painDillicult swlllorungllcarrburn irxttg!\ttxiConstip.timDirrdra

SkloRa.hDcrrurtrtrs or cczcn.rPl'li$tcnt hclir8

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Coffce clps rlayRcgular lxh. cons dayDia xrda. cons day

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Sandoz Chirop.aclic Ltntcr - Phonc: 856-206-9560 l-ax: E56-206-970tfr9lldeskrir,sandqjlhi1qllselis.com r.Ery.scodszghiratracli9.cam

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Canilo-U rlorr)Psinful uriaatiotl-oss of Hadder crrrrrolFrquo udnariurUttiral rlisrhar3c

Plc!r. che.l lnJ of th. follo$ing thot rpply to you.

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\?SANT'o,Z,i cnlRopRACTtc

=,I)iI'0RJII!,D CONSENT T-OR CIUROPRACTIC Al, IIIANIPIILATIOTT'. DIAGNOS'IIC X-RAYSAND TR}:A'I'i\IEN'I. AUTIIORIT.ATION AND RELEASEI lErcby rcquesl ard consent to the pc.formanc. ofchi.opBclic 6djusrrnents s{d oficr chiropractrc procedurg, iocludlngvarious modes oftheopy modalitics (includitrg but oot limited to ultrasound, musclc s mulation, intcrfercntial, icc, beat,traction, spiial dccompressioo) and diagnostic x-rays, on m;self(or on thc patient oamcd bclorv for rvhim I am lcgallyre{onsible) by or under rE ordc.s of lhc liccoscd doclors ofchiropractic ofdrc Saodoz Chiropractic Ctntcr or lqy doclor.who nolv or in lha fufuae, rrorl$ as s dief dock r.

I havc lBd th€ opporiutrity ro discoss with my doctor the natue and purposc olchiropractic adJustmcnt5 and proc.durEs srdundcnitalld fiat spinal nraniprlation involvcs thc doctor placin8 his oI hcr hands on my spinc detvcri[g a quick duust orimpulsc to lhe involvrd area(s) I also understand and arn iaformed th8t, as in tlr. practicc ofmcdlcrnc, in thc practicc ofchiropractic thcre arc somc .isks to trcatrEDt it|cludrlg, but rrct lmitcd to: fr8€tur€s, drsc iruuries, stokes, dislocations,sprarns, soreocss, and phy:iical thcrapy bums I undcrstard and coorprchcnd all such risk rnd cornplications and rcaliz-e

that shemalilcs lo carc might includc rrdical trcatrncnt. surgery or doing lahing I, by nry signaturc belorv, conlinu ardacccpt care and drercfore conscnt to eod rgrcr lo thosa trcarncnls dccnrd nccc;sary by ory doctor Io be in my besl intcrest

I authorizc pdynrenl of usurancc benclits drecdy to the Sardoz Chiroptactrc Ccntcr- I understand and agrce lo lllow thisoffice to us. uy Confid€nlial Palierlt tleal$ lnformatioo fonns for tk puDo* ofUcalmcnt, paynrent, h.allhcarc op.ration\and coordrnatron ofEsre a.!d luthorize thc Sandoz Chiropoctic Ccnt$ 10 coflnrunicatc wrth Ery mcdrcalph) iicia(s) about

my condrtions and trcatrltcot I understrnd aird agrce that I am rcsponsiblc for all cosrs ofcfurofnactic carc, regardhss ofiosuoncc covemgc I also agcc tbat if my account goes into a 'collcclioo state' for non-pa;ment a charge of 3l9r will be

irruncd on the lotalamouol o$cd I also undcrstsnd and rgrcc dlat ifl surperd o. tcrminate my schcdulc ofcarc ns

dete.mincd by nry lreatitrg doctor, any fccs for professional services rvill bc im0redrately due and payablc I undcatand drc

Fcdcral Gorenrrredlt hrs d€icrned it rnandalory to noliry my doctor ofaoy othcr pany or rnsunrre company who may be

responsiblc for rcimbursernenl for my lrcalnranl.

I ha\r'c rEad lnd uoderstari how my Patieor gcalth loformltioD rull bc uscd ald I s8re€ lo lhere polrcies and ptoccdutes I

harc also rcad, or havc lnd tead to me tlr abovc infomrcd corsc.rll, nuthorization and rclca* t har c Lidd an opponurily to

ask any aud all queslroos shrt ih co tent, and by signing belorv, I .grEc to &c rbovc-flantcd proccdures I inlend for lhiscorl\rnl fornr to co\er thc cotirt cou$e oftaeatnrcut for nty prcscot condrlroo a[d for fulure coodttions(s) for $'hich I leek

trcatlllcnt

Patient's Sig,nature:

Printed Narne.

l)atc:

c{)NstrN't 'I0 r R}./\1 ill or A NOR CI[t,r)I hcrcby lurhorize the doctors of Sandoz Chiopraclic Cenle., lnd or $,rhomevcr lhey may dc\iSnatc ss assi{nor' to

odmrnistff lrcatrncat as dccmcd ceccs.sary to

SBnaturc of l'are or legal Suardlan Rclatrooshig

Dat. Wllncss Sigtrsture'

X-RAY PR}:GN^NCY RELf,ASE FORJU

'lb the bast afr!) linorvlcdgc. I om NOT prcgnart lnd I consent to protectrd Rcdlognph eryrc.sue at SandorChiropraclic Ccnte,

I am or nray bc prcgrunt. hoiye\er, I csNcol to hmitad 9role:(tad lrrltrostrc Radrographs ofmy Cervic.l Spirr'(Ncck)

I)ate:

Sandoz Cbiroproclic Ccder - Phone: 856-20G9560 Fsx. 856-2069701f'-o,nld9*lilder_chi&Draetic.com 1,11114qublsbU_qEcatis,cCg

Patient's Signaturc: