Covington Family Chiropractic Patient Intake Form

APPLICATION FOR CARE
Today's Date: *

Month Day Year
Date
HR#:
PATIENT DEMOGRAPHICS
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Age *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work Phone:
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Mobile Phone: *
Please enter a valid phone number.
Patient Email: *
example@example.com
How did you hear about our office?
Marital Status: *

Single Married Widowed Divorced
Do you have insurance?   No   Yes*
Social Security #:   Number   Driver's License #:   Number
Employer:      Occupation:
Spouse's Name   First Name   Last Name   Spouse's Employer
Number of children and ages: 1.     2.      3.      4.      5.      6.      7.
Name of Emergency Contact:   First Name*   Last Name*Contact Number:   Area Code*   Phone Number*Relationship:

Patient Name *

First Name Last Name
HR#
Date *

Month Day Year
Covington Family Chiropractic LLC

Informed Consent

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often very minimal, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke-which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.

Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Covington Family Chiropractic LLC have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.
Patient Name *

First Name Last Name
Patient or Authorized Person's Signature *

Clear
Date *

Month Day Year
Witness Initials
FEMALES ONLY: Please read carefully, check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our front desk staff for further explanation

The first day of my last menstrual cycle was on Date
I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant

By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic X-ray examination the doctor has deemed necessary in my case.
Patient Name (Print)

First Name Last Name
Patient or Authorized Person's Signature

Clear
Date

Month Day Year
Witness Initials

Patient Initials: blanks*-retaining page 1 of 2
(Covington Family Chiropractic LLC) NOTICE REGRADING YOUR RIGHT TO PRIVACY continued..

I have received a copy of Covington 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.
Patient's Name: *

First Name Last Name
DOB *

Month Day Year
Patient's Signature: *

Clear
Date: *

Month Day Year
Witness:

Clear
Date:

Month Day Year

Covington 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. Jamie Adams at (770) 786-2818 If she is unavailable, you may make an appointment with our receptionist to see her 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

Medical Information Release Form

(HIPAA Release Form)
Release of Information: *

I authorize the release of Information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:
Spouse
Child(ren)
Other
Information is not to be released to anyone.
The Release of information will remain in effect until terminated by me in writing.
Please call (my home) Area Code Phone Number . (my work) Area Code Phone Number .(my mobile) Area Code* Phone Number*.
If unable to reach me: *

You may leave a detailed message Please leave a message asking me to return your call Other
If other:
The best time to reach me is (day) Date between Time toTime .
Signed: *

Clear
Date: *

Month Day Year
Witness:

Clear
Date:

Month Day Year
Patient Id
Clinic Name
Should be Empty:

	Past	Currently	Never
Broken Bone
Heart Attack
Dislocations
Osteo Arthritis
Tumors
Diabetes
Theumatold Arthritis
Cerebral Vascular
Fracture
Disability
Cancer

	How Long Ago	Type Of Care	Provided By Whom
Injuries
Surgeries
Childhood Diseases
Adult Diseases

	P	N	C
Headache
Neck Pain
Jaw Pain, TMJ
Shoulder Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Hip Pain
Back Curvature
Scoliosis
Numb/Tingling arms, hands, fingers
Numb/Tingling legs, feet, toes
Pregnant (Now)
Frequent Colds/Flu
Convulsions/Epilepsy
Tremors
Chest Pain
Pain w/Cough/Sneeze
Foor or Knew Problems
Sinus/Painful Joints
Skin Problems
Dizziness
Loss of Balance
Fainting
Double Vision
Blurred Vision
Ringing in Ears
Hearing Loss
Depression
Irritable
Mood Changes
ADD/ADHD
Allergies
Prostate Problems
Impotence/Sexual Dysfunction
Digestive Problems
Colon Trouble
Diarrhea/Constipation
Menopausal Problems
Menstrual Problem
PMS
Bed Wetting
Learning Disability
Eating Disorder
Trouble Sleeping
Ulcers
Heartburn
Heart Problem
High Blood Pressure
Low Blood Pressure
Asthma
Difficulty Breathing
Lung Problems
Kidney Trouble
Gall Bladder Trouble
Liver Trouble
Hepatitis (A,B,C)

	No Effect	Painful (can do)	Painful (limits)	Unable to Perform
Carry Children/Groceries
Sit to Stand
Climb Stairs
Pet Care
Extended Computer Use
Lift Children/Groceries
Read/Concentrate
Getting Dressed
Shaving
Sexual Activities
Sleep
Static Sitting
Static Standing
Yard Work
Walking
Washing/Bathing
Sweeping/Vacuuming
Dishes
Laundry
Garbage
Driving

APPLICATION FOR CARE

PATIENT DEMOGRAPHICS

HISTORY OF COMPLAINT

PAST HISTORY

FAMILY HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS

Medical Information Release Form

	1	2	3	4
List Restricted Activity
Current Activity Level
Usual Activity Level