Warren Chiropractic Care Center

Name: __________________________

Date: __________________________

Child Information

Name: ___________________________ Date of Birth: ______________ Social Security #: _________________

Address: _________________________________________________City: __________ State: _____ Zip: __________

Home phone number: ______________________Age: _____________________ Gender: _____________________

Parent Information

Name: __________________________Employer: ____________________ Occupation:________________________

Home Phone: _________________ Work Phone: ________________ Social Security #: __________________

Marital Status: ________________________ E-mail: ________________________

Experience With Chiropractic

Who may we thank for referring you to this office? ________________________________________

Have you ever been adjusted by a chiropractor? □ Yes □ No

Doctor’s Name? ___________________________________________

Has any adult in you family seen a Chiropractor? □ Yes □ No

Has any other child in your family seen a Chiropractor? □ Yes □ No

Child Health Information

Has your child been vaccinated? □ Yes □ No

Has you child ever taken antibiotics? □ Yes □ No

Has you child ever been hospitalized? □ Yes □ No

Has you child ever had a severe fall? □ Yes □ No

Has your child ever been in a car accident? □ Yes □ No

Is you child accident prone? □ Yes □ No

Has you child ever had surgery? □ Yes □ No

Child Health History □ Allergies □ Frequent Colds □ Colic □ Sleeping disorders

□ Asthma □ Headaches □ Constipation □ Tubes in the ears

□ Attention problems □ Hyperactivity □ Digestive problems □ Vision problems

□ Bed Wetting □ Irritability □ Ear problems □ Other

□ Breathing Problems □ Skin Problems

Name: __________________________

Date: __________________________

Reason for this visit

Please Describe the reason for this visit:________________________________________________

When did this condition begin? _________________________________________________________

Has this Condition:

Does this condition interfere with:

Has this condition occurred before? Yes □ No □

Have you seen other doctors for this condition? Yes □ No □

□ Gotten worse □ Stayed the same

□ Comes and goes

□ daily routine □ Sleep

□ other activities

Mother’s Pregnancy and Labor

During pregnancy, any: □ Drugs/Medicine used □ Tobacco/Alcohol consumed

Any illness during pregnancy? Yes □ No □

Labor & Delivery (please check those that apply)

Did you nurse the baby? Yes □ No □

Did your baby have colic? Yes □ No □

Feeding problems? Yes □ No □

□ Labor chemically induced □ Labor was Dr. assisted

□ C-section delivery □ Forceps/Vacuum extraction?

□ Did Dr. pull or twist baby? □ Premature delivery?

Goals for my Child’s Care Based on what you currently know about Health and Wellness, are you interested in

a care plan based solely on:

1. Pain relief

2. Corrective care

3. wellness care

Each care plan focuses on goals that require varying lengths of time and amount of

patient participation.

Are Your Symptoms worse with any of the following?

(please circle)

On a scale of one to ten, how does your condition affect you?

1 2 3 4 5 6 7 8 9 10

Daily Activities Can Do Limited Unable to perform

Bending No Effect mild Moderate Severe

Computer Use No Effect mild Moderate Severe

Bathing No Effect mild Moderate Severe

Walking No Effect mild Moderate Severe

Eating No Effect mild Moderate Severe

Sports No Effect mild Moderate Severe

Terms of Acceptance

When a patient seeks Chiropractic health care, and we accept a patient for such care, it is essential for both to be working for the

same objective. Chiropractic has only one goal. It is important that each patient understands both the objective and the method

that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: The adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation.

Our chiropractic method of correction is by specific adjustments of the spine.

Health: The state of optimal physical, mental, and social well being., not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes altercation of

nerve function and interference to the transmission of mental impulses, resulting in a lessening if the body’s innate ability to

express it maximum health potential.

We do not offer diagnosis or treat any disease. We only offer to diagnosis either vertebral subluxation or neuro-

musculoskeletal conditions. However, during the course of a chiropractic spinal examination we encounter non-chiropractic or

unusual findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that

you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment pre-

scribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body’s

innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures

I, _______________________________________________ have read and fully understand to above statements.

SIGNATURE

All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete

satisfaction.

Therefore, I accept chiropractic care on this basis.

_______________________________________________ ________________________________________

SIGNATURE DATE

Privacy Notice Acknowledgement In accordance with th Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a

copy of out privacy policies and procedures. We encourage you to read this document carefully, as it outlines the uses and limita-

tions of the disclosure of your health information and rights as a patient. If you have any questions or concerns regarding this

notice, we will be happy to address them.

I acknowledge that I have received a copy of Warren Chiropractic Care Center’s Notice of Privacy Practices.

____________________________________________ ____________________ SIGNATURE DATE

Patient Policies

Financial Policy

Warren Chiropractic Care Center has devel-

oped a Financial Policy in an effort to help

you, our patient, understand our fees and fi-

nancial obligations. We want you to know

what to expect before you receive care, so we

may move

comfortably forward and focus on what is

most important, YOUR HEALTH! Please review

our financial policy thoroughly. A member of

our staff will be happy to answer any ques-

tions you may have. ALL PAYMENTS ARE DUE AT

THE TIME

SERVICES ARE RENDERED. Acceptable forms of

payment include: cash, most major credit

cards, Debit/check cards, and personal

checks.

All insurance assignment patients must pay

their

deductibles in full and the co-payment at

the time of service.

The office utilizes the services of a collec-

tion agency for past due accounts. All ac-

counts due over 90 days are submitted for

collection.

Payment plans are available for those who

qualify.

Insurance Assignment

Warren Chiropractic Care Center will qual-

ify your insurance coverage in an effort to

help determine exactly what

chiropractic coverage is available under

your policy. All deductibles must be paid in

full prior to insurance submittal. All co-

payments are payable when services are ren-

dered. (Co-payment is that part of our ser-

vice that is not paid by your insurance).

Since we do not own your policy, and, since

insurance assignment is a privilege, it may be

terminated at any time. Of course we will

give you ample notice and ask that you act

on your own behalf with your insurance

company. All patients whose visitation

schedule is on maintenance or a wellness

program maybe ineligible for insurance as-

signment.

Worker’s Compensation &

auto Accident Patients

Please provide us with your insurance infor-

mation and claim number prior to the com-

mencement of your care. Any interruptions

in care that exceed eight weeks will not be

eligible for reinstatement.

Children

Children under the age of 18 must be with a parent at each visit unless we

have written permission by a parent which states that Warren Chiropractic

Care Center is allowed to treat the child and they are able to sign in at

each visit. All payments are due at the time the services are rendered. A re-

ceipt will be given each time the child is here as proof of payment. If you de

not receive one, please let us know so we can verify payment of visit. Parent

must be present at each Report of Findings for progress update.

All patients

It is the goal of this office to provide you with the finest quality chi-

ropractic care available. If you have any questions with regard to

you health care, or any of our patient policies, please let us know. We

welcome your referrals and look forward to a doctor-patient rela-

tionship that works for our mutual benefit.

We ask that you sign this form as an acknowledgment that our policy

was explained to you, that you fully understand and accept the

terms of this financial policy.

Name: _________________________________________________________________________

Signature: ___________________________________________________________________

Date: ________________________________