Adult Patient Form | Bozeman Chiropractic

Please complete this form in its entirety. ALL INFORMATION IS KEPT CONFIDENTIAL.

Patient Information:

First Name Address City

State

Zip Code

Home Phone

Alt Phone

Last Name

Date of Birth

Last 4 Digits of SSN

Spouse or Nearest Relative

Sex Male Female

Children Email

Employment Information:

Employer Occupation Work Phone

Employer Address City

State

Zip Code

General Information:

If referred to my office, by whom?

Have you ever been to a chiropractor before?

Yes No

When was your last visit?

Do you have any symptoms?

Yes No

What are they and how have they affected your life?

If this is work related, have you reported
it to your employer?

Yes No

Is this related to an auto accident?

Yes No

What is the date of the accident?

Are you currently under any medical care?

Yes No

Have you been treated for any health conditions
by a Medical Doctor in the last year?

Yes No

Please explain:

Are you pregnant?

Yes No Not Sure

Coverage Information:

If the Doctor determines that services are necessary,
all charges are payable when rendered. What form
of payment will you use?

Cash Check Credit Card

Are you insured?
(If yes, please show proof of insurance to Receptionist)

Yes No

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Abundant Health Family Chiropractic, P.C. will prepare any necessary reports and forms to assist me in making collection from the insurance company. I clearly understand and agree that all services rendered 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 and treatment, any fees for professional services rendered me will be immediately due and payable. I hereby authorize the doctor at Abundant Health Family Chiropractic, P.C. (AHFC) and whomever they may designate as their assistants to administer any care, as they deem necessary. I certify that the above information is true and correct.

In the event that I make a special arrangement with AHFC, P.C. to bill insurance for me I authorize the release of any medical or other information necessary to process the claim. I also request payment of government benefits either to myself or to the party who accepts assignment.

This statement is effective for 24 months, unless sooner revoked in writing.

Print Name

Date

Terms of Acceptance:

When an individual seeks chiropractic health care and I accept this individual for such care, it is essential for both to be workingtowards the same objective. Chiropractic has only one goal. The goal is to eliminate Subluxations within the spinal column, which interferes with the expressionof the body's innate wisdom. It is important that you as the patient understand both the objective and the method that will be used to attain our goal. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral Subluxation. My chiropractic method of correction is specific adjustments of the spine and extremities.

Health: A 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 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to expressits maximum health potential. Ancillary treatment: In addition to spinal adjustments I may adjust subluxations in other joints of the body. When necessary Imay also recommend specific exercises and /or therapies such as ice, heat, electrical stimulation or ultrasound. I do not offer to diagnose or treat any disease or condition other than Subluxation. However, if during the course of chiropractic examination we encounter non-chiropractic or unusual findings, I will advise you.

If you desire advice, diagnosis, treatment for thosefindings, I will recommend that you seek the services of a health care provider who specializes in the area. Regardless of what the disease is called, I do not offer to treat it. Nor do I offer advice regarding treatment prescribed by others. MY ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body's innate wisdom. My method is specific adjusting to correct vertebral and joint Subluxations.

I have read and fully understand the above statements.

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If you have questions, or if for any reason you would rather us send you forms through mail or email, don't hesitate to call us at:

Big Sky Office: 406.993.2233
Bozeman Office: 406.585.7000
or email us at info@abundanthealthchiro.net