Patient Intake Form Patient Intake Form 1Patient Info 2Insurance Information 3Review of Symptoms 4Health History 5Assignment and Release 6Consent for care treatment 7Privacy Practices 8Patient Consent 9X-Ray 10Erisa Authorization 11Informed Consent Patient Info Your Name(Required) First Middle Last Your Address Street Address Apt/Suite City State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific ZIP Code Home Phone Work Phone Cell Phone Email Date of Birth MM slash DD slash YYYY Employment StatusEmployed Unemployed Student Other Marital StatusMarried Divorced Widow Single Legally Separated Spouse Data Spouse Name First Middle Last Spouse Home Phone Spouse Work Phone Spouse Cell Phone Spouse Email Address Spouse Date of Birth MM slash DD slash YYYY Employer Data Employer Name/Occupation Employer Name Dr. Miss Mr. Mrs. Ms. Mx. Prof. Rev. Occupation Address Street Address Apt/Suite City State / Province / Region ZIP / Postal Code Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Arab Republic Taiwan Tajikistan Tanzania, the United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Emergency Contact Contact Name First Last Relationship to Patient Emergency Phone - Home Emergency Phone - Work Emergency Phone - Cell Emergency Email Address Insurance Information Upload Insurance Drop files here or Select files Max. file size: 50 MB. Primary Insurance Do you have Insurance? Yes No Secondary Insurance Do you have Secondary Insurance? Yes No Worker’s Compensation Injury / Auto / Personal Injury Have you filed an injury report with your employer? Yes No Review of Symptoms Are you pregnant? Yes No N/A Where you are experiencing the symptoms? Spine Neck Head Hips Shoulders Elbows Wrists Ankles Feet Describe your symptoms in order of severity, with worse symptom being #1 When did your symptoms begin? MM slash DD slash YYYY Are your symptoms a result of Motor Vehicle Accident Work related Accident Other How often do you experience your symptoms?Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) What describes the nature of your symptoms? (Check all that apply) Sharp Dull ache Numb Shooting Burning Tingling Stabbing Does the pain radiate? Yes No Health History What treatment have you already received for your condition? Medication Surgery Physical Therapy Chiropractic Services None Are your currently under the care of a Healthcare Provider or any other doctor? Yes No Provider’s Name First Provider’s Phone Number Date of last Physical Exam MM slash DD slash YYYY Date of last Spinal Exam MM slash DD slash YYYY Date of last Blood Test MM slash DD slash YYYY Date of last Spinal Xray MM slash DD slash YYYY Date of last MRI, CT Scan Bone Scan MM slash DD slash YYYY Please Mark Yes or No if you have had any of the following AIDS/HIV Diabetes Liver Disease Rheumatic Fever Alcoholism Emphysema Measles Scarlet Fever Allergy Shots Epilepsy Migraine Headaches Anemia Fractures Miscarriages Stroke Anorexia Glaucoma Mononucleosis Suicide Attempt Appendicitis Goiter Multiple Sclerosis Thyroid Problems Arthritis Gonorrhea Mumps Tonsilitis Asthma Gout Osteoperosis Tubercolosis Bleeding Disorders Heart Disease Pacemaker Tumors Growths Breast Lump Hepatitis Parkison’s Disease Typhoid Fever Bronchitis Hernia Pinched Ulcers Builinis Herniated Disk Pneumonia Vaginal Infections Cancer Polio Whooping Cough Cataracts High Blood Pressure Prostate Problems Lupus Rheumatoid Arthritis High Cholesterol Prosthesis Chicken Pox Kidney Disease Psychiatric Care Other Exercise None Moderate Daily Heavy Work Activity Sitting Standing Light Labor Heavy Labor Habits Smoking Light Moderate Heavy Alcohol Light Moderate Heavy Coffee/Caffeine Drinks Light Moderate Heavy Stress Level Light Moderate Heavy Injuries you have had Injuries Dislocations Head Injuries Broken Bones Surgeries Falls Medications Allergies Vitamins/Herbs/Supplements Assignment and Release for insurance benefits I certify that I, and or my dependent(s) have insurance coverage with [IKnaTgHRNz] and assign benefits directly to First Name Last Name Broadway Chiropractic and Wellness.I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office, will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care or treatment, any fees for professional services rendered to me will be immediately due and payable. Name(Required) First Middle Last Date of Birth MM slash DD slash YYYY Patient’s Signature(Required) Date MM slash DD slash YYYY Doctor’s Signature(Required) Date MM slash DD slash YYYY Consent for care treatment I, the undersigned do hereby agree and give consent to JEFFREY KLEIN DC, Broadway Chiropractic and Wellness LLP and Associated Chiropractors, to furnish medical care and treatment to the patient listed below that is considered necessary and proper in diagnosing or treating his/her physical and/or mental condition. Name(Required) First Middle Last Date of Birth MM slash DD slash YYYY Patient’s Signature Date MM slash DD slash YYYY Doctor’s Signature Date MM slash DD slash YYYY Privacy Practices Notice Of Privacy Practices Acknowledgement I understand that under the ​Health Insurance Privacy & Accountability Act of 1996 (HIPAA) I have certain rights to privacy regarding my protected health insurance. I understand that this information can and will be used to : ​Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly and indirectly. ​Obtain payment from third party payers. ​Conduct normal healthcare operations such as quality assessments and physician certification. I acknowledge that I have reviewed your ​Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its ​Notice of Privacy Practices ​from time to time and that I may obtain a current copy of the Notice of Privacy Practices​.I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do not agree that you are bound to abide by such restrictions. Signature(Required) Date MM slash DD slash YYYY I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below: Date MM slash DD slash YYYY Initials Reason Patient Consent I hereby give my consent for Jeffrey Klein DC, Broadway Chiropractic & Wellness, to use and disclose protected health information about me to carry out treatment, payment and healthcare operations. Jeffrey Klein DC, Broadway Chiropractic & Wellness, Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to singing this consent. Jeffrey Klein DC, Broadway Chiropractic & Wellness, reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: Broadway Chiropractic & Wellness1410 Broadway 39t h Street SuitNew York, NY 1001 With this consent form, Jeffrey Klein DC, and staff of Broadway Chiropractic & Wellness , may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminders, insurance items and any calls pertaining to my clinical care including laboratory results, amongothers. With this consent form, Jeffrey Klein DC, Broadway Chiropractic & Wellness, may mail, to my home or other alternative location, any items that assist in carrying out treatment, payment or healthcare operations such as appointment reminder cards and patient statements as long as they are marked personal and confidential. With this consent form, Jeffrey Klein DC, Broadway Chiropractic & Wellness, may email, to my home or other alternative location, any items that assist the practice in carrying out treatment, payments or healthcare operations such as appointment reminders. I have the right to request that Jeffrey Klein DC, Broadway Chiropractic & Wellness, restrict how it uses or discloses my protected health information (PHI) to carry out treatments, payments and healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Jeffrey Klein DC, Broadway Chiropractic & Wellness,use and disclosure of PHI to carry out treatment, payment and healthcare operations. I may revoke my consent in writing except to the extent the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent or later revoke it, Jeffrey Klein DC, Broadway Chiropractic & Wellness, may decline to provide treatment for me. Name(Required) First Middle Last Signature(Required) Date MM slash DD slash YYYY X-Ray Patient Consent Form I, [firstName] [lastName] authorize the performance of diagnostic x-ray examination of myself which Drs. Klein, or Bobrowsky may consider necessary or advisable in the course of my examination and treatment. Name(Required) First Middle Last Date MM slash DD slash YYYY I, am the parent or legal representative of [NbRuMbnQOE] [QiknvlmhZK] who is a minor, [taNyRxEbYJ] years of age. I authorize the performance of diagnostic x-ray of this minor which Drs. Klein, or Bobrowsky may consider necessary or advisable. Name First Middle Last Age Please enter a number greater than or equal to 0. Date MM slash DD slash YYYY Regarding possibility of pregnancy this is to certify that, to the best of my knowledge, I am not pregnant, and Drs. Klein, or Bobrowsky have my permission to perform diagnostic x-ray examination. I have been advised that certain x-ray examinations, particularly those involving the pelvis, can be hazardous to an unborn child. Signature Date MM slash DD slash YYYY Erisa Authorization For good and valuable consideration, I [firstName] [lastName] , do hereby designate, authorize, and convey to Broadway Chiropractic & Wellness to the full extent permissible under law and under any applicable Insurance policy and/or employee health care benefit plan. A) the right and ability to act on behalf in connection with any claim, right or chose in action that I may have under such Insurance policy and/ or employee health care benefit plan(including but not limited to, the right to act in my behalf in respect to an employee health care benefit plan governed by the provisions of the Employee Retirement Income Security Act of 1974 as provided in 29 CFR §2560.503-1(B)(4)) with respect to any medical or other health care expense incurred as a result of the services I received from the above-named doctor and, to the extent permissible under the law, to the claim on my behalf, such medical or other health care service benefits, insurance or health care benefit plan reimbursement and any other applicable remedy. Name(Required) First Middle Last Signature Date MM slash DD slash YYYY Informed Consent CHIROPRACTIC It is important to acknowledge the difference between the health care specialists of chiropractic, osteopathy and medicine. Chiropractic health care seeks to restore health through natural means without the use of medicine or surgery. This gives the body maximum opportunity to utilize its inherent recuperative powers. The success of the chiropractic doctors procedures often depend on environment, underlying causes and spinal conditions. It is important to understand what to expect from chiropractic health care services. ANALYSIS A doctor of chiropractic conducts a clinical analysis for the express purpose of determining whether there is evidence of Vertebral Subluxation Complex (VSC). When such vertebral subluxation complexes are found, chiropractic adjustments and ancillary procedures may be given in an attempt to restore spinal integrity. It is the chiropractic premise that spinal alignment allows nerve transmission throughout the body and gives the body an opportunity to use its inherent recuperative powers. Due to the complexities of nature, no doctor can promise you specific results. This depends upon the inherent recuperative powers of the body. INFORMED CONSENT FOR CHIROPRACTIC CARE A patient, in coming to the doctor of chiropractic gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis and analysis. The chiropractic adjustment or other clinical procedure are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give a chiropractic adjustment, or health care, if he is aware that such care may be contraindicated. Again, it is the responsibility of the patient to make known or to learn through health care procedures whatever he/she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the doctor of chiropractic. The patient should look to the correct specialized, non-duplicating health service. The doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regime.We like to advise our patients with neck problems of the following: In recent years there have been rare incidents of injury to the vertebral artery during the course of care by medical doctors, physiotherapists and chiropractors. The risk of stroke after cervical adjustment is 0.00025%. To put this in perspective, the risk of stroke in the general population is 0.00057% and the risk of death from taking aspirin and other anti-inflammatory drugs is .04%. Tests will be performed on you to minimize this risk and an appropriate adjustment technique will be applied. Chiropractic care is considered to be one of the safest and most effective forms of care. RESULTS The purpose of chiropractic services is to promote natural health through the reduction of vertebral subluxation complex. Since there are so many variables, it is difficult to predict the time schedule efficacy of the chiropractic procedures. Sometimes the response is phenomenal. In most cases there is a more gradual but quite satisfactory response. Occasionally, the results are less than expected. Two or more similar conditions may respond differently to the same chiropractic care. Many medical failures find quick relief through chiropractic. In turn, conditions, which do not respond to chiropractic care, may come under control or be helped through drugs or surgery. The fact is that the science of chiropractic and medicine may never be so exact as to provide definite answers to all problems. Both have made great strides in alleviating pain and controlling disease. TO THE PATIENT Please discuss any questions or problems with the doctor before signing this statement of policy. I have read and understand the foregoing. Name(Required) First Middle Last Date MM slash DD slash YYYY
