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 ZIP Code

Home Phone

Work Phone

Cell Phone

Date of Birth

MM slash DD slash YYYY

Employment Status

Marital Status

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 Occupation

Address

Street Address Apt/Suite City State / Province / Region ZIP / Postal Code Country

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

Max. file size: 50 MB.

Primary Insurance

Do you have Insurance?

Yes

Secondary Insurance

Do you have Secondary Insurance?

Yes

Worker’s Compensation Injury / Auto / Personal Injury

Have you filed an injury report with your employer?

Yes

Review of Symptoms

Are you pregnant?

Yes

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?

What describes the nature of your symptoms? (Check all that apply)

Sharp

Dull ache

Numb

Shooting

Burning

Tingling

Stabbing

Does the pain radiate?

Yes

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

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 & Wellness
1410 Broadway 39t h Street Suit
New 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

Patient Intake Form