AFC Application For Care

Health History Form

Anchor Family Chiropractic-- 55 Freedom Pkwy /Ste 112/ Hoschton, GA 30548
Full Legal Name*

First NameLast Name
Parent/Legal Guardian Full Name
*If Patient is Under 18 Years of Age
Name you prefer to be called:
(If different)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:*
How did you hear about us?*
If at an event, please put the event name. If referred by a practice member, please put their name.
Birth Date*

MonthDayYear
Age*
Male/Female
Phone Number*

Area CodePhone Number
Email*
example@example.com
Marital Status*

SingleEngagedMarriedDivorcedWidowed
Spouses Name
Name, Age & Gender of Children*

FAMILY HISTORY
Diabetes*
Heart Disease*
Cancer*
Stroke*
Arthritis*
ADD/ADHD*
Ear Infections*
Allergies/Asthma*
Digestive Issues*
Deceased:

MotherFatherSonDaughterOther
SOCIAL HISTORY
Do you smoke?*

YesNoNot Any More
Number of of packs per day
Alcohol, Number of drinks per week*
Water, Number of cups per day*
Have you ever had any spinal taps/spinal injections?*
List current medications (prescriptions and/or over-the-counter).*
List any known allergies.*
How many hours do you sit per day?*
How many hours do you stand per day?*
I have provided accurate and complete information to the best of my knowledge.
ELECTRONICALLY SIGNED BY*
Type legal name above
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MonthDayYearHourMinutesAM/PM Option

Terms of Acceptance

In order to provide for the most effective healing environment, most effective application of chiropractic procedures, and the strongest possible doctor-patient relationship, it is our wish to provide each patient with a set of parameters and declarations that will facilitate the goal of optimum health through chiropractic.

To that end, we ask that you acknowledge the following point regarding chiropractic care and the services that are offered through this facility:
- Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. Chiropractic is a separate and distinct science, art and practice. It is not the practice of medicine.
- Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functions through the adjustment of spinal subluxation(s). Subluxations are deviations from normal spinal structures and configurations that interfere with normal nerve processes.
- The chiropractic adjustment process, as defined in the law of this jurisdiction, involves the application of a specific directional thrust to a region or regions of the spine with the specific intent of re-positioning misaligned spinal segments. This is a safe, effective procedure applied over one million times each day doctors of chiropractic in the United States alone.
- A thorough chiropractic examination and evaluation is part of the standard chiropractic procedure. The goal of this process is to identify any spinal health problems and chiropractic needs. If during this process, any condition or question outside the scope of chiropractic is identified, you will receive a prompt referral to an appropriate provider or specialist, according to the initial indications of the need.
- Chiropractic does not seek to replace or compete with your medical, dental or other type(s) of health professionals. They retain responsibility for care and management of medical conditions. We do not offer advice regarding treatment prescribed by others.
- Your compliance with care plans, home and self-care, etc., is essential to maximum healing and optimal health though chiropractic
  We invite you to speak frankly to the doctor on any matter related to your care at this facility, its nature, duration, or cost, in what we work to maintain as a supporting, open environment.
By my signature below, I have read and fully understand the above statements.

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my satisfaction. I therefore accept chiropractic care on this basis.
ELECTRONICALLY SIGNED BY*
Type legal name above
Date

WRITTEN CONSENT FOR A CHILD

I AUTHORIZE DR. KATHERINE GEE AND ANY AND ALL QUALIFIED ANCHOR FAMILY CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES AND RADIOGRAPHIC EVALUATIONS TO MY MINOR/CHILD IF DEEMED NECESSARY. I HEREBY AUTHORIZE DR. KATHERINE GEE AND ASSOCIATE DOCTOR(S) TO RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.

AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY ANCHOR FAMILY CHIROPRACTIC.
Parent/Legal Guardian Name
*Required if Patient is Under 18 Years of Age
ELECTRONICALLY SIGNED BY*
Type legal name above
DateTime

INFORMED CONSENT FOR CHIROPRACTIC CARE

CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A CEREBROVASCULAR ACCIDENT.

PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.

I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT.
ELECTRONICALLY SIGNED BY*
Type legal name above
Date

X-RAY AUTHORIZATION

AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF YOUR X-RAYS FROM OUR FILES FOR A $20 FEE FOR THE DISC. DIGITAL X-RAYS ON A CD WILL BE AVAILABLE WITHIN 48 HOURS ON ANY REGULAR PRACTICE HOURS DAY.

PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF ANCHOR FAMILY CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.

BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS.
ELECTRONICALLY SIGNED BY
Type legal name above
Date
FEMALES ONLY: TO THE BEST OF MY KNOWLEDGE, I AM NOT PREGNANT AT THE TIME X-RAYS ARE TO BE TAKEN AT ANCHOR FAMILY CHIROPRACTIC.
ELECTRONICALLY SIGNED BY
Type legal name above

PHOTO/VIDEO CONSENT

I, hereby grant Anchor Family Chiropractic and its representatives the right to use and reproduce any video footage, audio recordings, and photographs captured during my care for advertising, promotional, educational, and related purposes.

I understand and agree to the following terms:

1. **Authorization:** I grant Anchor Family Chiropractic the non-exclusive, perpetual right to use, reproduce, distribute, and display the aforementioned content in all forms of media, including but not limited to print, television, radio, website, social media, and promotional materials.

2. **Ownership:** I acknowledge that Anchor Family Chiropractic owns all rights, title, and interest in the content captured, and I waive any claims to compensation for its use.

3. **Release:** I release Anchor Family Chiropractic, its employees, agents, contractors, and any third parties acting under its authority, from any liability, claims, or demands arising out of the use of the content, including but not limited to claims for defamation, invasion of privacy, or infringement of rights.

4. **No Compensation:** I understand that I will not receive any compensation, financial or otherwise, for the use of the content.

5. **Model Release:** I authorize Anchor Family Chiropractic to use my likeness, and voice in connection with the content.

6. **Minor Participants:** If the participant is a minor, I am the parent/legal guardian of the minor, and I give my consent for their participation and for the use of their content as described in this release form.

7. **Revocation:** I understand that I can revoke this consent at any time.

I have read and understand the terms outlined in this release form, and I am of legal age and competent to sign this agreement. I have signed this release willingly and voluntarily.

By signing below, I acknowledge that I have obtained the necessary consent from the participant or their parent/legal guardian, if applicable, and agree to abide by the terms outlined in this Photo & Video Release and Consent Form.

ELECTRONICALLY SIGNED BY
Type legal name above
Date
Anchor Family Chiropractic LLC NOTICE OF PRIVACY PRACTICE

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled ‘HIPAA’ on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

PERMITTED DISCLOSURES:
1. Treatment purposes - discussion with other health care providers involved in your care.
2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
4. For workers compensation purposes - to process a claim or aid in investigation.
5. Emergency - in the event of a medical emergency we may notify a family member.
6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner and government benefits purposes.
9. Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death.
10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.
11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.
YOUR RIGHTS:
1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive “Detail” Privacy Notice.
3. To request mailings to an address different than residence.
4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.
COMPLAINTS:

If you wish to make a formal complaint about how we handle your health information, please call Dr. Katie Geeat (678)-35-9828. If they are unavailable, you may make an appointment with our receptionist to see them within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to

DHHS, Office of Civil Rights

200 Independence Ave. SW

Room 509F HHH Building

Washington DC 20201

I have received a copy of Anchor Family Chiropractic LLC Patient Privacy Notice. I understand my rights as well as the practice’s duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this “Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.
ELECTRONICALLY SIGNED BY*
Type legal name above
Date:
Should be Empty:

	Type of Condition (i.e. Neck Pain)	Severity 0-10 (0= none, 10=worst possible)	When did it start? (days/months/years)	Did it begin with an injury?
Problem #1
Problem #2
Problem #3
Problem #4

	Never	In the Past	Current
Spinal Surgery
Stroke
Heart Attack
Heart Disease
Varicose veins
Difficulty breathing
Cancer
Diabetes
Rapid Weight Loss/Gain
Rheumatoid Arthritis
Facial Paralysis
Seizures/Epilepsy

Health History Form